Fundamentals Ch 9 Recording & Reporting

Front 1

Written collection of information about the clients health, the care provided by the health care provider & the clients progress

Back 1

Medical Record

Front 2

hard copy paper form of clients medical record

Back 2

chart

Front 3

this gives patients basic information or demographics...name address, DOB, etc

Back 3

Fact sheet

Front 4

written chronological account of patients illnesses progress & treatments

Back 4

permanent account

Front 5

central communication is

Back 5

sharing information

Front 6

this makes you keep up to agency standard, continuous quality improvement, or totally quality improvement

Back 6

Quality assurance

Front 7

this type of record contains separate forms from all providers Dr, nurse, PT, OT, dietary etc. can be bad because all the info is scattered

Back 7

Source oriented record

Front 8

This type of record is organized by the clients health problems

Back 8

problem oriented record

Front 9

This method of charting generally used in source oriented records. it involves writing info about the client in chronological order, remembles a journal

Back 9

Narrative

Front 10

Soap charting is used in problem oriented record. The S.O.A.P. stands for

Back 10

Subjective
Objective
Analysis of Data
Plan of care

Front 11

This form of charting is a modied form of soap charting...uses a more positive word instead of problem...

Back 11

Focus charting

Front 12

What does PIE charting mean?

Back 12

Problem
Intervention
Evaluation

Front 13

in this form of charting nurses only chart abnormal finding

Back 13

charting by exception

Front 14

this is a reference of current information about the client care, changes constantly

Back 14

nursing kardax

Front 15

this is marked with initials or a check mark stating the nurse did something...often used for ADLs

Back 15

check lists

Front 16

visiting with clients on an individual basis or as a group HIPPA can become an issue

Back 16

client rounds

Front 17

when taking orders from a physician on the telephone what steps should be taken to insure that the correct order is taken

Back 17

have two nurses on the phone, clarify & verify the information