Term
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Definition
to get used to reporting on patients.
informal method of communicating with another HC professional. going on all the time |
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Term
| why do we document in a chart? |
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Definition
communication
auditing agents
reimbursements
research
education
legal reasons |
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Term
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Definition
| if you didn't chart it you did not do it. |
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Term
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Definition
18
can have a lawsuit up to age 18 years of age. If you didn't chart something when person a baby, you are liable |
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Term
| how is the chart multidisciplenary? |
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Definition
| pt record is a vehicle for the professional to communicate with each other. Chart is multidesiplenary |
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Term
What is the difference between a discussion and a report? |
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Definition
a record is written or computer based
and a discussion is informal communication by more than one health care professional to convey a problem or to resolve a problem |
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Term
| what is the purpose of client records? |
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Definition
communication
planning client care
auditing health care agencies
research
education
reimbursement
legal documentation
health care analysis |
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Term
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Definition
| the record serves as a vehicle by which different health professionals who interact with a client communicate with each other. |
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Term
| what does communication prevent? |
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Definition
| fragmentation, repetition, and delays in client care |
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Term
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Definition
-
A record is written or computer based.
• Making an entry in a record is a process called recording, charting or documenting. |
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Term
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Definition
documentation in a pts chart establishes a baseline for the pt
the chart is an avenue to evaluate the outcome of the ongoing care and effectiveness of a care plan |
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Term
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Definition
| JCAHO may review client records to determine if a particular health agency is meeting its stated standards |
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Term
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Definition
| treatment plans for a number of clients with the same health problems can yield information helpful in treating other clients |
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Term
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Definition
| provides comprehensive view of the client, illness, effective treatment strategies, and factors that affect the outcome of the illness |
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Term
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Definition
| the client's record must contain the correct diagnosis-related group (DRG) |
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Term
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Definition
| admissible in court as evidence. can be inadmissable if client objects, because of client confidential |
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Term
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Definition
| identify agency needs, overutilized and underutilized hospital services |
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Term
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Definition
Source-oriented record
problem-oriented medical record
PIE
Focus Charting
computerized documentation
case management |
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Term
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Definition
| traditional client record. each department makes notations in a separate section or sections of the client's chart |
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Term
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Definition
| not used much anymore except in emergencies. written notes that include routine care, formal findings, and client problems |
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Term
| advantage/disadvantage of source-oriented charting |
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Definition
• An advantage is the care giver can easily locate the section in which they should document
• A disadvantage is details about a specific problem may be located through out the chart. Hunting for where you need to document.
• It is inefficient because interventions that apply to more than one problem must be repeated
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Term
Problem Oriented Medical Record |
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Definition
• Problem-Oriented documentation
• This method of documentation places an emphasis on the patient’s problems.
• An advantage is it encourages collaboration and the patient’s problem list in located in the front of the chart |
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Term
| 4 basic components of POMR |
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Definition
database
problem list
plan of care
progress notes |
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Term
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Definition
subjective data
objective data
assessment
plan |
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