Documentation

Question 1

What is the purpose of a legal record?

Answer 1

• verifies need for care
  -nurses held accountable for actions
  -can be used in court

Question 2

What is a source record?

Answer 2

separate section for each discipline

Question 3

What is a clinical/critical pathway?

Answer 3

only charts deviations from the pathway

Question 4

When taking notes what is the DAR method?

Answer 4

Data, Action, Response

Question 5

When taking notes what is the PIE method?

Answer 5

Problem, Intervention, Evaluation

Question 6

When taking notes what is the SOAP method?

Answer 6

Subjective, Objective, Assessment, Plan

Question 7

What can be included on a omitted care document?

Answer 7

incident reports