DOCUMENTING/REPORTING Flashcards
This is an oral, written, or computer-based
communication intended to convey information
to others.
record
This is a formal, legal document that provides evidence of
a client’s care and can be written or computer
based.
RECORD
The process of making an entry on a client
record
REPORTING, CHARTING, DOCUMENTING
Reporting and recording are the major
communication techniques used by health
care providers.
DOCUMENTATION AS COMMUNICATION
The client understands the reasons and risks of the
proposed intervention.
INFORMED CONSENT
The problems the client has rather than
the source of the information
PROBLEM ORIENTED MEDICAL RECORD
Who established POMR
LAWRENCE WEED
It includes nursing assessment, the primary
care provider’s history, social and family data,
and the results of the physical examination
and baseline diagnostic tests
DATABASE
It includes nursing assessment, the primary
care provider’s history, social and family data,
and the results of the physical examination
and baseline diagnostic tests
PROBLEM LIST
Generated by the individual who list the problems.
PLAN OF CARE
a chart entry made by all health professionals involved in a client’s care; they all use the same type of sheet for notes.
PROGRESS NOTE
Uses a structured, logical format
SOAPIE
SOAPIE stands for
SUBJECTIVE DATA OBJECTIVE DATA ASSESSMENT PLANNING IMPLEMENTATION EVALUATION
It consists of written notes that include routine care, normal findings, and client problems.
TRADITIONAL CLIENT RECORD
Describes the client’s status, interventions and treatments; response to treatments is in story format.
NARRATIVE CHARTING
