Documentation Flashcards
- Written or computer-based
- Served as a permanent record of client’s information and progress care
- Formal, legal document that provide evidence of a client’s care
Documentation
What are the purposes of documentation?
- Planning client care
- Communication
- For legal documents purposes
- For research
- For education
- Reimbursement
- For statistics, reporting, epidemiology
- Auditing health agencies
- Health care analysis
What are the two types of records?
- Source-Oriented Medical Record (Traditional Client Record/ SOMR)
- Problem-oriented Medical Record
Each person or department makes notations in a separate section/s of client’s chart and specific information is easier to locate
Source-Oriented Medical Record (Traditional Client Record/ SOMR)
- Data about the client are recorded and arrange according to the sources of the information
- Records integrates all data about the problem, gathered by members of health team
PROBLEM-ORIENTED MEDICAL RECORD
What are the 4 basic components of the PROBLEM-ORIENTED MEDICAL RECORD?
- Database
- Problem lists
- Plan of care
- Progress notes
• Provides a concise method of organizing and recording data about the client, making information readily
accessible to all members of the health care team
• May be written in a pencil to ease in recording frequent change in details of client care
• A series to flip cards usually kept in portable file
Kardex
What are the general guidelines for recording?
- date and time
- timing
- legibility
- permanence
- use of accepted terminology
- correct spelling
- signature
- accuracy
- sequence
- appropriateness
- completeness
- conciseness
- legal prudence
- confidentiality
Takes place when two or more people share information about client care, either face-face o via telephone
REPORTING
What are the 4 types of reporting?
- Change-of-shifts report or endorsement
- Telephone Reports
- Telephone Orders
- Transfer Report
