Documenting 15

Question 1

Narrative charting

Answer 1

Traditional part of source-oriented record. Written notes of routine care, normal findings

Question 2

Problem oriented medical record POMR

Answer 2

Data arranged according to problems client has

Question 3

Progress notes

Answer 3

In POMAR: made by all care professionals

Question 4

SOAP

Answer 4

Subjective data
Objective data
Assessment
Plan

Question 5

SOAPIE

Answer 5

Interventions
Evaluation
Revision

Question 6

Flow sheet

Answer 6

Specific assessment criteria in a particular format, like human needs or functional patterns

Question 7

Focus charting

Answer 7

Client concerns and strengths the focus of care
DAR
Data action response

Question 8

Charting by exception

Answer 8

Only abnormal or significant findings are recorded

Question 9

Variance

Answer 9

Goal that is not met

Question 10

Source oriented record

Answer 10

Traditional. Separate departments