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Nursing Documentation Post Test Objective #5

Horizontales
Focus, action, data, response
Reflects the evaluation phase of the nursing process
Tasks that are applied to ensure wellness
Current condition
Used to document how patients problems are being treated and evaluating responses to interventions
Health record of patient
Verticales
Charting by exception
Planning & implementing the nursing process
Systems review, test & results
Identifies patient centered concerns
Problem oriented documentation
Problem oriented medical record