charting by exception (CBE)

Documenting only unexpected or unusual findings

computerized provider order entry (CPOE

Allow providers to enter and transmit prescription electronically

electronic health records (EHRs)

Systemic, digitized documentation system used to improve medical records. A computerized, real-time form of a client's paper chart that can be shared between members of the interprofessional team.

Proper documentation practices, stands for factual, accurate, complete, and timely.

Centers on specific health care problems and the change in condition, client events and concerns. Three items must be documented: data, action, and response (DAR)

Health Insurance Portability and Accountability Act (HIPAA)

Established by the federal government with the goal of making healthcare more efficient.

A collection of health information and data about an individual client s health

Part of HIPAA. Established in 2003, it created regulations that govern EHR records to protect the privacy of healthcare consumers.

Type of documentation that omits the plan of care and utilizes flow sheets and progress notes.

problem-oriented medical record (POMR)

Used to create a comprehensive and organized approach among all members of the interdisciplinary team.

source-oriented medical record

Traditional form of documentation, divided into specific sections within the medical record.

An order received over the telephone from a provider when the provider is not physically present.

Orders received from a provider directly, transcribed by licensed personnel, and later cosigned by the provider.

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ATI Module

Documentation (Exam 1)

Question	Answer
charting by exception (CBE)	Documenting only unexpected or unusual findings
computerized provider order entry (CPOE	Allow providers to enter and transmit prescription electronically
electronic health records (EHRs)	Systemic, digitized documentation system used to improve medical records. A computerized, real-time form of a client's paper chart that can be shared between members of the interprofessional team.
FACT	Proper documentation practices, stands for factual, accurate, complete, and timely.
focus charting	Centers on specific health care problems and the change in condition, client events and concerns. Three items must be documented: data, action, and response (DAR)
Health Insurance Portability and Accountability Act (HIPAA)	Established by the federal government with the goal of making healthcare more efficient.
health record	A collection of health information and data about an individual client s health
HIPPA Privacy Rule	Part of HIPAA. Established in 2003, it created regulations that govern EHR records to protect the privacy of healthcare consumers.
PIE model	Type of documentation that omits the plan of care and utilizes flow sheets and progress notes.
problem-oriented medical record (POMR)	Used to create a comprehensive and organized approach among all members of the interdisciplinary team.
source-oriented medical record	Traditional form of documentation, divided into specific sections within the medical record.
telephone order	An order received over the telephone from a provider when the provider is not physically present.
verbal orders	Orders received from a provider directly, transcribed by licensed personnel, and later cosigned by the provider.

Created by: user-1977236

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