Chap15documentation
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| What is the purpose of client records? | Communication,planning, auditing, research, education, reimbursement, legal documentation, and health care analysis.
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| What is source oriented record? | Narrative charting. It is traditional and in story-like format.
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| 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
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| 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.
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| What does the POMR include? | Database,Problem list,plan of care,and progress notes.
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| What format is the progress notes in the POMR? | SOAP
Subjective, Objective, Assessment, and Plan.
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| 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.
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| 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.
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| What is charting by exception (CBE)? | is when only abnormal or significant findings or exceptions to the norms are recorded.
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| What are some guidelines for documentation? | Date and time, timing,legibility, permanence, and terminology.
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