FUND Ch. 19 documentation

Question 1

charting by exception

Answer 1

only document significant findings or exceptions

Question 2

documentation

Answer 2

written/electronic legal record - assessing, diagnosing, planning, implementing, evaluating

Question 3

EHR - electronic health record

Answer 3

computer-based records

Question 4

focus charting

Answer 4

brings focus of care back to the patient and the patient’s concerns

Question 5

graphic record

Answer 5

form used to record specific patient variables such as vitals

Question 6

patient record

Answer 6

compilation of a patients health information

Question 7

personal health record

Answer 7

ability to manage health care via a computer

Question 8

PIE charting

Answer 8

system that does not develop a separate care plan, plan is incorporated into the progress notes and identifies problems by number

Question 9

problem-oriented medical record

Answer 9

paper record, organized around a patients problems rather than sources of information

Question 10

progress notes

Answer 10

notes are written to inform caregivers of the progress a patient is making toward achieving expected outcome

Question 11

SOAP format

Answer 11

subjective data, objective data, assessment, plan

Question 12

Variance charting

Answer 12

patient fails to meet expected outcome or planned intervention not implemented, variance from case managment plan is documented