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7 Cards in this Set
- Front
- Back
Source-oriented Record |
Group keeps data on its own separate form |
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Problem oriented medical records |
Patient problem rather than sources of information. (SOAP) S- subj. infor. Reported by pat. O-obj. Observ. By practitioners A-asses. Drawn from new data P-plans or goals for action related to patients problem |
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PIE CHARTING |
system in unique in that it does not develop a separate plan of care |
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Focus Charting |
Bring focus of care back to patient and the patients concern |
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Charting By Exception |
A shorthand documentation method that makes use of well defined standards of practice |
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Case management Model |
Promotes collaboration, communication, and team work among care givers |
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Personal Health Records |
Individually manage care via computer |