chapter 9: recording + reporting

The Joint Commission

is a private association that has established criteria reflecting high standards for client safety and institutional health care.

Problem-Oriented Records

*organized according to client's health problems *four major components: data base, problem list, plan of care, progress notes.

Source- Oriented Records

*organized according to the source of documented information *contains separate forms for physicians, nurses, dietitians, and physical therapists to make written entries about their specific activities in relation to client's care *provided fragmented documentation

The _____ is considered a legal document.

medical record

auditors

inspectors who examine client records

the four essential components of SOAP charting

S- subjective data O- objective data A- analysis of the data P- plan for care

Which charting method involves writing information about the client and client care in chronological order? a. SOAP b. PIE c. Narrative d. Focus

C. Narrative charting

medical records

is a collection of information about a person's health, the care provided by healthcare providers, and the client's progress

Repetitious entry of same information

Double charting

Nurses use the _____ to obtain quick access to current information about client.

Kardex

Charting is organized according to problem, intervention, and evaluation.

PIE

_____ are primary resources for health information

Published references

True or False: Source- oriented records contain separate forms for all entities to make different entries

True: Source-oriented records contain separate forms for physicians, nurses, dietitians, and physical therapists to make written entries about their specific activities in relation to client's care.

change-of-shift report

a discussion between a nursing spokesperson from the shift that is ending and the arriving personnel

Charting by Exception

a documentation method in which nurses chart only abnormal assessment findings or care that deviates from a standard norm

flow sheet

a form of documentation with sections for recording frequently repeated assessment data

Focus charting

a modified form of SOAP charting.

Kardex

a quick reference for current information about the client and his or her care

nursing care plans

a written or printed list of the client's problems, goals, and nursing orders for client care

Military time

based on 24 hour clock

checklist

documentation in which the nurse indicates the performance of routine care with a check mark or initials

Charting by ______ is a documentation method in which nurses can chart only abnormal assessment findings or car that deviates from the standard

exception

beneficial disclosures

exemptions when agencies can release private health information without the client's prior authorization.

PIE charting

method of recording the client's progress under the headings of problem, intervention, and evaluation

SBAR format

model for effective communication identifying S-ituation B-ackground A-ssessment R-ecommendation

methods of charting

narrative SOAP focus PIE charting by exception computerized

Checklist

nurses use this to document the types of care that are regularly repeated briefly and efficiently

uses of medical records

permanent account, sharing information, quality assurance, accreditation, reimbursement, education and research, legal evidence

quality assurance

process for promoting care that reflects established agency standards

HIPAA

protects the rights of US citizens to retain their health insurance when changing employment.

SOAP charting

the documentation style more likely to be used in a problem-oriented record. Acquired its name from four essential components included in a progress note.

charting, reporting, documenting

the process of entering information

Narrative charting

the style of documentation generally use in source-oriented records. Involves writing information about to the client and client care in chronological order.

Traditional time

two 12 hour revolutions

rounds

visits to the bedside of clients on an individual basis or as a group