Record Keeping

Question	Answer
4 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
6 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
DOCAP-D	discussion -write about topic spoken recording is made by use of key words -Apects relative to the client or family -Subjective and objective data
DOCAP-5 Observation	seen, heard, or assessed during the visit -People ( age, well being) visitors Place-internal & external environment Social Systems(economic, coping Nursing Process Approach -
DOCAP-Changes	occurred since the last visit -no changes indicate -people -place -eniroment
DOCAP-Actions	Nurse client/family verb written in the same order as observation Education
DOCAP-Plan	client, family, nurse mutual agrred -activities that will occur next visit -referrals
5 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

Resource summary

	Created by shanice.simmons8 over 10 years ago