Documentation For Advanced Practice Nurses Page 7
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8plan must be in the note and on the
SOAP notes are extremely difficult to
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plan of care form.
work with for nurses who have 8 to 12
hours of constant contact with a
Many people have difficulty deciding
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patient. They are best used in clinical
where information needs to be
situations where nurses make
placed—is it subjective or objective
summary notes for a day, week, or
data? Is the data assessment or
month at a time.
evaluation?
The format isn’t suited for fast patient
This format is time-consuming to write
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turnover.
and read due to the repetitive
charting.
Documentation Type: Electronic
Strengths
Charting is legible.
Notes can be organized the same
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from author to author.
Several people can have access to
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the same record at the same time.
You always know where the chart is.
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Prompting is available to remind the
This method promotes documenting
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person charting about what to chart.
the nursing process.
All changes to the record can be
It decreases problems in maintaining
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tracked.
adequate charting forms and
supplies.
The system can be modified to meet
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facilities’ particular needs.
Weaknesses
The facility must make a major cash
This method requires a major
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investment for equipment, software,
psychological change for staff. They must
and training.
overcome their fear of computers and
must adjust how they work and organize
Many people need to be trained to
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their time.
use a computer and to overcome
their fear of computers.
Documentation may be inaccurate if the
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practitioner doesn’t carefully read each
If the hardware or software crashes,
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phrase picked from a menu.
you lose access to the chart.
Documentation Type: Open Charting
Strengths
Encourages patients to review their
Fosters patient inclusion in the
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own patient care record
healthcare delivery process
Promotes meticulous documentation
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by healthcare providers
Weaknesses
Requires significant time
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Could raise patient queries regarding the
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healthcare delivery
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