Midterm_Documentation

Question 1

Its a legal document that provides evidence of client’s care. Has different systems and form of documentation. But all have similar information about the client

Answer 1

Chart or Client Record

Question 2

Its the process of making an entry on a client record. AKA charting or documenting

Answer 2

Recording

Question 3

What are the purposes of recording?

Answer 3

1. Communication
2. Planning client care
3. Auditing health agencies
4. Research
5. Legal Documentation
6. Reimbursement

Question 4

Types of Charting

Answer 4

1. narrative charting
2. focus charting
3. progress notes

Question 5

Identify what type of charting is being described:
- traditional part of source oriented records
- consist of written notes that include routine care, normal fundings, and client problems

Answer 5

Narrative Charting

Question 6

Identify what type of charting is being described:
- FDAR
- intended to make client and client concerns the focus of care
- provides holistic perspective of the client and the client’s needs

Answer 6

Focus Charting

Question 7

Identify what type of charting is being described:
- SOAPIE
- Subjective data, objective data, assessment, plan, intervention, and evaluation

Answer 7

Progress Notes