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DOC & REPORTING
DOCUMENTING & REPORTING
| Question | Answer |
|---|---|
| WHAT IS THE RECORDING OF THE PATIENT'S STATUS & CARE IN WRITTEN FORM | DOCUMENTATION |
| WHAT IS ORAL COMMUNICATION ABOUT A PATIENTS STATUS | REPORTING |
| WHAT IS A LEGAL RECORD OF THE CLIENTS HEALTHCARE EXPERIENCES | CLIENT RECORD |
| WHAT ARE THE 2 TYPES OF DOCUMENTATION | SOURCE-ORIENTED RECORDS & PROBLEM ORIENTED RECORDS |
| DEMOGRAPHICS INFORMATION, INS DATA, CONTACT INFO, ECT.... WHERE IS THIS DONE AT? | ADMISSION |
| THIS IS THE CLIENT'S WISHES FOR WHAT KIND OF CARE TO BE DONE IN AN EMERGENCY. | ADVANCED DIRECTIVE |
| THIS IS A SUMMARY OF THE CURRENT PROBLEM AND PAST MEDICAL AND SOCIAL HISTORY. | HISTORY & PHYSICAL |
| ORDERS FOR MEDICATION, TREATMENT ECT (NEW ORDERS) | PHYSICIANS ORDERS |
| CHARTING BY PHYSICIANS ON THE PATIENTS RESPONSES TO TREATMENT | PROGRESS NOTES |
| TEST FINDINGS SUCH AS X-RAYS, MRI ECT... | DIAGNOSTIC STUDIES |
| RESULTS FROM LAB WORK | LAB |
| NARRATIVE NOTES ARE CHRONOLOGICAL ON THE PTS RESPONSE TO TREATMENTS | NURSES NOTES |
| INTAKE AND OUTPUT RECORDS, VS FLOW SHEETS | GRAPHIC |
| THERAPISTS CHART ON THE PATIENTS RESPONSE TO TREATMENT, PT, OT AND RT | REHAB & THERAPY NOTES |
| THIS IS DONE ON PT'S NEEDS AFTER DISCHARGE,DISCHARGE PLANNING BEGINS WHEN A PT IS ADMITTED TO A HC FACILITY. | DCPLANNING |
| THIS TYPE OF DOCUMENTATION IS REGARDING PTS PROBLEMS WITH NO SEPARATE SECTIONS AND HAS FOUR COMPONENTS | PROBLEM ORIENTED RECORDS |
| THIS CONTAINS: DEMOGRAPHIC DATA, THE H & P, NURSING ASSESSMENT & SOCIAL HISTORY | DATABASE |
| THIS IS A LIST OF PROBLEMS IDENTIFIED FROM THE DATABASE | PROBLEM LIST |
| THIS INCLUDES THE PHYSICIANS ORDERS AND THE NURSING CARE PLAN FOR THE IDENTIFIED PROBLEM | PLAN OF CARE |
| THIS IS WHERE NOTES ARE ORGANIZED ACCORDING TO THE PROBLEM LIST. EACH DISCIPLINE CHARTS ON SHARED NOTES | PROGRESS NOTES |
| THIS IS WHERE THE PTS STATUS & PROGRESS TOWARD HIS GOAL. A DISADVANTAGE WOULD BE RAMBLING AND NOT ORGANIZING THE DATA. NURSES NOTES | NARRATIVE |
| THIS IS SUBJECT DATA, OBJECTIVE DATA, ASSESSMENT, AND PLAN. USUALLY USED TO ADDRESS A SINGLE PROBLEM | SOAP |
| THIS IS FOR PROBLEMS, INTERVENTIONS AND EVALUATIONS. PROBLEMS NUMBERED | PIE CHARTING |
| CHARTING IS DONE IN 3 COLUMNS-1.TIME & DATE 2. IDENTIFIES THE PROBLEM 3. CHARTING IN A DAR FORMAT | FOCUS CHARTING |
| THIS REDUCES TIME REQUIRED TO CHART. IT USES PREPRINTED FLOWCHARTS TO DOCUMENT & UNLESS A SEPARATE ENTRY IS MADE, ALL PROBLEMS ARE MET AND THE PT RESPONDED WELL | CHARTING BY EXCEPTION |
| CLINICS, MD OFFICES ECT HAS INSTRUCTIONS ON HOW TO USE THE MEDICATIONS | OUTPATIENT |
| WE DOCUMENT MEDS GIVEN ON THE MAR (MEDICATION ADMINISTRATION RECORD) | INPATIENT |
| INJECTIONS, ASSESSMENT, DRUG ALLERGIES, PRN, PATIENT REFUSAL AND OMITTED MEDS OR DELAYED ADMINISTRATION ARE ALSO CHARTED ON THE | MAR |
| THIS TYPE OF SHEET IS USED TO DOCUMENT FREQUENT ASSESSMENTS AND CARE, VS, I & O'S EVERY 8 HRS | FLOWSHEETS |
| ASSESSMENTS AND CARE MAY BE RECORDED ON | CHECKLISTS |
| THIS MONITORS I & O FOR FLUID OVERLOAD OR DEFICIT | INTAKE |
| THIS IS WHERE YOU DOCUMENT INTERVENTIONS AND PATIENTS RESPONSE TO THEM | PROGRESS NOTES |
| THIS IS A FORM THAT BRIEFLY SUMMARIZES AND THE PATIENTS PLAN OF CARE | KARDEX |
| THE LAST ENTRY IN THE CHART | DISCHARGE |
| FOR OCCURRENCES OR ACCIDENTS AND ARE NOT PART OF THE PTS CHART. DONT WRITE IN NN | OCCURANCE OR INCIDENT REPORTS |
| THIS IMPROVES LEGIBILITY (LES MISSTAKES DUE TO POOR HANDWRITING) | COMPUTERIZED CHARTING |
Created by:
jmbosworth1972
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