Nursing Progreess-ch15: Documenting and Reporting

Question 1

a formal, legal document that provides evidence of a client’s care

Answer 1

Chart

Question 2

the process of making an entry on a client record

Answer 2

Charting

Question 3

a documentation system in which only significant findings or exceptions to norms are recorded

Answer 3

Charting by exception (CBE)

Question 4

an informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem

Answer 4

Discussion

Question 5

the process of making an entry on a client record; charting, recording

Answer 5

Documenting

Question 6

a record of the progress of specific or specialized data such as vital signs, fluid balance, or routine medications; often charted in graph form

Answer 6

Flow sheet

Question 7

a method of charting that uses key words or foci to describe what is happening to the client

Answer 7

Focus charting

Question 8

the trade name for a method that makes use of a series of cards to concisely organize and record client data and instructions for daily nursing care–especially care that changes frequently and must be kept up to date

Answer 8

Kardex

Question 9

a descriptive record of client data and nursing interventions, written in sentences and paragraphs

Answer 9

Narrative charting

Question 10

an acronym for a charting model that follows a recording sequence of problems, interventions, and evaluation of the effectiveness of the interventions

Answer 10

PIE

Question 11

data about the client are recorded and arranged according to the client’s problems, rather than according to the source of the information

Answer 11

Problem-oriented medical record (POMR)

Question 12

chart entries made by a variety of methods and by all health professionals involved in a client’s care for the purpose of describing a client’s problems, treatments, and progress toward desired outcomes

Answer 12

Progress Notes

Question 13

a written communication providing formal, legal documentation of a client’s progress

Answer 13

Record

Question 14

the process of making written entries about a client on the medical record

Answer 14

Recording

Question 15

an acronym for a charting method that follows a recording sequence of subjective data, objective data, assessment, and planning

Answer 15

SOAP

Question 16

a record in which each person or department makes notations in a separate section or sections of the client’s chart

Answer 16

Source-oriented clinical record

Question 17

a variation or deviation from a critical pathway; goals not met or interventions not performed according to the time frame

Answer 17

Variance

Question 18

a report given to nurses on the next shift

Answer 18

change of shift report