DOCUMENTATION Flashcards
an informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem
discussion
oral, written, or computer based communication intended to convey information to others
report
it is a formal, legal document that provides evidence of a client’s care and can be written or computer based
record/chart/client record
the process of making an entry on a client record is called
reporting/charting/documenting
the client’s record is protected legally ; it is a _ record
private
__ is the rightful owner of the client’s record
institution or agency
the student or health professional must protect the client’s privacy by not using a __ or __ that would identify the client
name or any statement
the traditional client record is a _ record ; notations in a separate section or sections of the client’s chart
source-oriented record
traditional part of the source-oriented record ; consists of written notes that include routine care, normal findings, and client problems ; no right or wrong order to the information, just chronological
narrative charting
who established the problem oriented medical record
lawrence weed
record that encourages collaboration and problem list in the front of the chart alerts caregivers to the client’s needs and makes it easier to track the status of each problem
POMR
consists of all information known about the client when the client first enter the health care agency
database
derived from database ; kept at the front of the chart and serves as index to the numbered entries in the progress notes
problem list
is a chart entry made by all health professionals involved in a client’s care
progress note
it is where the statement of the problem should be ; description of the client’s condition and level of progress
assessment
it is primarily the reassessment data
evaluation
intended to make the client and client concerns and strengths focus of care
focus charting
meaning of FDAR
focus
data
action
response
in fdar, it reflects the planning and implementation ; immediate and future nursing action ; changes on the plan of care
action
in fdar, it reflects the evaluation phase of the nursing process
response
used to manage the huge volume of information required in contemporary health care
EHR
it emphasizes quality, cost-effective care delivered within an established length of stay ; uses a multidisciplinary approach to planing and documenting
case management
a goal that is not met is called a__ ; deviation from what was planned on the critical pathway
variance
it should describe the client’s ongoing status and reflect the full range of the nursing process
client record
