Chapter 9 Recording and Reporting
Nurses use ___________ to document the types of care that are regularly repeated briefly and efficiently.
flow sheet
_____________ charting is used to document client information electronically.
Computerized
Computerized charting
Electronic charting
PIE charting is organized according to problem, intervention, and ____________.
Evaluation
Charting by _______ is a documentation method in which nurses chart only abnormal assessment findings or care that deviates from the standard.
Exception
Health Insurance Portability and Accountability Act (HIPAA) is responsible for accreditation of health agencies. True or False
False
Narrative charting is organized according to client problems rather than time
False. Narrative charting resembles a log or journal and involves writing info about the patient in chronological order.
Health Insurance Portability and Accountability Act (HIPAA) regulations make it mandatory to have names of clients publicly visible on charts.
False. This would be a privacy violation
6 Methods of charting
Focus, Narrative, SOAP, PIE, Exception & Computerized.
Focus charting
Follows the DAR method: Data, Action, Response.
Nurses us the __________ to obtain quick access to current information about a client.
Kardex
________collections of information about a persons health, the care provided by health practitioners and client's progress.
Medical records
Charting by exception
Nurses chart only abnormal assessments.
PIE charting
Problem, Intervention, Evaluation.
SOAP charting
Subjective, Objective, Analysis, Plan for care. Problem-oriented records.
Source-oriented records provide a documentation approach that is sometimes criticized for being fragmented or disjointed. True or False
True. Source-oriented records are organized according to their source. MD, nurses, PT,OT, etc. All jumbled together.
Narrative charting
Written information about client care in chronological order. Generally in source-oriented records
Two types of client records_____and ______.
source-oriented (organized according to source) and problem-oriented record (organized according to client's health problems.