Documentation Flashcards
Problem-oriented medical records (POMR)
- Documents organized by problems/behaviors. priorities assigned to each problem. Chart entries by problem
- Charts divided into 5 sections:
1. Data base
2. Problem list
3. Plans
4. Progress notes
5. Discharge summary
DARP
Data Action Response Plan
Focus charting identifying clients concerns and behaviors
Document assessment, implemented client experience and other services into the DARP categories
PIE charting
Problem, Intervention and Evaluation
TRS would combine objective and subjective data to produce problem list, document interventions addressing problems and evaluations
Flow Charting
document services and programs by the sequence in time in which client will receive service
Then document clients response and results
Charting by exception (CBE)
only charting findings that are significant or deviate from professional protocols, standards or clinical pathways. Negative and positive variances
SOAP Subjective
Narrative statements from client, observable narratives (found patient on floor next to bed)
SOAP Objective
Measurements age, weight, vitals, test rest;its, physical examination findings
SOAP Assessment
physicians medical diagnosis made on date of note
SOAP Plan
Intended provider treatment action (referrals, tests, procedures, medication)
SMART system
Specific, Measurable, Attainable, Realistic and Timely
Used to write goals and objectives
Formative Evaluations
During treatment making immediate decisions about objective adjustments and alternative intervention strategies
Summative Evaluation
after intervention evaluate treatment effectiveness
Documenting Adverse Incident
Hrs must immediately report any error to supervisor
Should include:
- name
- other identifying information
- time, date & location
- Narrative
