Flashcards
Record Keeping
Cards in this deck (8)
- 14 DOCAP facts-recording of home visits in the Bahamas
-recorded after home visit
-must b written in past tense
-factual, confidential, legible, signed and date - 26 pts explanation of DOCAP (problem oriented-method of recording) POMR-only DPH has it
-places emphasis on client's identified problem
-written data in an easily accessible manner
-incoprarates ongoing plan of care into daily documentation
-subjective, objective, assessment, plan
-problem solving - 3DOCAP-Ddiscussion -write about topic spoken
recording is made by use of key words
-Apects relative to the client or family
-Subjective and objective data - 4DOCAP-5 Observationseen, heard, or assessed during the
visit
-People ( age, well being) visitors Place-internal & external environment
Social Systems(economic, coping
Nursing Process
Approach
- - 5DOCAP-Changesoccurred since the last visit
-no changes indicate
-people
-place
-eniroment - 6DOCAP-ActionsNurse
client/family
verb written in the same order as observation
Education - 7DOCAP-Planclient, family, nurse
mutual agrred
-activities that will occur next visit
-referrals - 85 Characteristics of family-small social system
-it's own cultural values and rules
-has a structure
-certain basic functions
-moves thru the stages in it's life cycle
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- Commuit Theory Flashcards on Record Keeping, created by shanice.simmons8 on 22/02/2014.
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- shanice.simmons8
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