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.