Six main methods of charting

Question 1

organized by “source” or author of the charting entry. records are organized according to the course of information. requires documentation of pt care in chronologic order (similar to dated and timed journal entries)

Answer 1

Source oriented (narrative) charting

Question 2

focuses on pts status emphasizing the problem solving approach to pt care and providing a method for communicating what when and how things are to be done to meet the pts needs. contains five parts. what are they

Answer 2

problem oriented medical record (POMR)

1)data base, the problem list, the plan, the progress notes, discharge summary

Question 3

centers on the patient from a positive perspective. directed at a nursing diagnosis, a pt problem, a concern, a sign, a symptom, or an event. has three components. what are they

Answer 3

focus charting
1)Data, Action and Response
(DAR)

Question 4

focuses on deviations from predefined norms, using preset protocols and standards of care. this charting is based on the assumption that all standards of practice are carried out and met with normal or expected response unless otherwise noted.

Answer 4

charting by exception

Question 5

where data are input to the computer

Answer 5

computer assisted charting

Question 6

tracks variances from the clinical pathway

Answer 6

case management system charting

Question 7

advantages of source oriented charting

Answer 7

give info on pts condition and care in chronologic order, indicates the pts baseline condition for each shift, includes aspects of all steps of the nursing process

Question 8

disadvantages of source oriented charting

Answer 8

encourages documentation of both normal and abnormal findings, requires extensive charting time, discourages physicians and other member from reading all parts of chart

Question 9

SOAPIER means

Answer 9

subjective info, objective data, assessment data, plan, implementation, evaluation, revision

Question 10

Advantages of POMR

Answer 10

provides documentation of comprehensive care by focusing on pts and their problems, promotes the problems solving approach, improves continuit of care and communication, easy auditing of pt records,

Question 11

what are the major components of the problem oriented medial record

Answer 11

database, problem list, plan, progress notes, discharge summary

Question 12

what does PIE charting stand for

Answer 12

Problem identification, interventions, evaluation

Question 13

advantages of focus charting

Answer 13

compatible with the use of nursing process, shortens charting time by using many flow sheets and checklists,

Question 14

disadvantages of focus charting

Answer 14

database is not complete, pt problems may be missed, does not adhere to charting with the focus on nursing diagnoses and expected outcomes

Question 15

computerized comprehensive record of a pts history and care across all facilities and admissions.

Answer 15

electronic health record (EHR)

Question 16

provides for efficient work flow because when orders are entered into the comp, they are automatically routed to the appropriate clinical areas for actions

Answer 16

Computerized provider order entry (CPOE)