Charting

Question 1

EMR

Answer 1

Electronic Medical Record

record of one episode of care

Question 2

EHR

Answer 2

Electronic Health Record

longitudinal record of health

Question 3

proper documentation

Answer 3

clear
accurate
accessible
timely
factual
nonjudgmental
proper grammar
date, time, signature

Question 4

Narrative

Answer 4

time consuming
lengthy
traditional

Question 5

Problem Oriented Medical Record

Answer 5

organizing documentation to place primary focus on patient’s individual problems
SOAP, SOAPIE, DAR, PIE

Question 6

PIE

Answer 6

Problem
Intervention
Evaluation

Question 7

APIE

Answer 7

Assessment
Intervention
Evaluation

Question 8

SOAP

Answer 8

Subjective
Objective
Assessment
Plan

Question 9

SOAPIE

Answer 9

Subjective
Objective
Assessment
Plan
Intervention
Evaluation

Question 10

DAR

Answer 10

Data
Action
Response

Question 11

CBE

Answer 11

Charting by Exception

records only abnormal and significant data

Question 12

flow sheets

Answer 12

can be converted to a graph

used to document routine care: vitals, meds, I/O

Question 13

HIPAA

Answer 13

Heath Insurance Portability and Accountability

Question 14

SBAR

Answer 14

Situation
Background
Assessment
Recommendation

Question 15

advantages of electronic charting

Answer 15

improves quality of nursing documentation
enhances patient safety
enhances communication

Question 16

disadvantages of electronic charting

Answer 16

computer and software failure

inaccessible in power outages

Question 17

DRG

Answer 17

diagnosis related groups