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Module (Breakdown Structure)

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1 Module (Breakdown Structure) on Mon Jul 06, 2009 9:13 pm

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Reflections of the Assessment
Findings to Charting


3 C's of Charting - Clarity, Conciseness and Consistency
Basic of Charting - Nurse Practice Acts/Accreditation
(JCAHO) Federal Guidelines (PRO/CQI/OBRA)
Reimbursement - DRG/CQI
Legal Considerations (Malpractice/Negligence)
Ethical - Advance Directives/Living Will
Formats of Charting - Narrative/POMR/SOAP/
SOAPIE/SOAPIER PIE/FACT/CBE - Charting by
Exception
Hazards of Charting

Assessment/IV and Treatment Chartings
Special Charting
(Neurological/Mechanical Ventilator)
Use of Flow Sheets
Transcribing order to MAR, KARDEX, CARE PLANS
Computerized/Automated Charting
General Validation/Evaluation

Face the Reality/Reporting Mechanism

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