DOCUMENTING AND REPORTING

Question 1

• Also called chart or client record
• Formal, legal document that provides
  evidence of a client’s care
• Can be written or computer based

Answer 1

Record

Question 2

ETHICAL AND LEGAL CONSIDERATIONS

HIPAA regulations updated on

Answer 2

April 14,
2003

Question 3

DOCUMENTATION SYSTEMS

Answer 3

• Source-oriented record
• Problem-oriented medical record
• Problems, interventions, evacuation (PIE)
  model
• Focus charting
• Charting by exception (CBE)
• Computerized documentation
• Case management

Question 4

• Traditional client record
• Each discipline makes notations in a
  separate section.
• Information about a particular problem
  distributed throughout the record
• Narrative charting
  o Written notes that include routine
  care, normal findings, and client
  problems
  o Often chronologic

Answer 4

Source-Oriented Record

Question 5

• Data arranged according to client problem
• Health team contributes to the problem list,
  plan of care, and progress notes.
• Encourages collaboration
• Easier to track status of problems
• Vigilance required to maintain problem list
• Assessments and interventions must be
  repeated when more than one problem
  exists.

Answer 5

Problem-Oriented Medical Record

Question 6

Ongoing client assessment flow sheet and
progress notes

Answer 6

PIE

Question 7

Focus on client concerns and strengths

Answer 7

Focus Charting

Question 8

Concise method of organizing and
recording data
* Series of cards kept in a portable index file
or on computer-generated form

Answer 8

Kardexes

Question 9

• Graphic Record
• Intake and Output Record
• Medication Administration Record|
• Skin Assessment Record

Answer 9

Flow Sheets

Question 10

• Provide information about progress client is
  making toward achieving desired outcomes
• Include information about client problems
  and nursing interventions

Answer 10

Progress Notes

Question 11

GENERAL GUIDELINES FOR RECORDING

Answer 11

Date and Time

Timing

Legibility

Permanence