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Chap15documentation

QuestionAnswer
What is the purpose of client records? Communication,planning, auditing, research, education, reimbursement, legal documentation, and health care analysis.
What is source oriented record? Narrative charting. It is traditional and in story-like format.
What are the components of the Source-Oriented Record? Admission sheet,Inital nurse assessment, Graphic record,Daily care rec,special flow sheets, med rec, nurses'notes,medical hist. & phys.exam,physician's order forms,physician's progress notes,Consult rec, Diag rep,consult rep,client discharge plan &ref sum
What is the problem-oriented med record (POMR)? Estab by Lawrence Weed in 1960s. Data is arranged according to the problem, not the source of info.
What does the POMR include? Database,Problem list,plan of care,and progress notes.
What format is the progress notes in the POMR? SOAP Subjective, Objective, Assessment, and Plan.
What is PIE? It groups info into 3 categories. Problem ,Interventions, and Evaluation. The flow sheet uses specific assessment criteria in a particular format such as human needs or functional health patterns. The time parameters can vary from minutes to months.
What is focus charting? intented to make client and client concerns and strengths the focus of care. Three columns used: date and time,focus and progress notes. Progress notes are organized into data,action, and response.
What is charting by exception (CBE)? is when only abnormal or significant findings or exceptions to the norms are recorded.
What are some guidelines for documentation? Date and time, timing,legibility, permanence, and terminology.
Created by: 706661534