Documenting 15 Flashcards
1
Q
Narrative charting
A
Traditional part of source-oriented record. Written notes of routine care, normal findings
2
Q
Problem oriented medical record POMR
A
Data arranged according to problems client has
3
Q
Progress notes
A
In POMAR: made by all care professionals
4
Q
SOAP
A
Subjective data
Objective data
Assessment
Plan
5
Q
SOAPIE
A
Interventions
Evaluation
Revision
6
Q
Flow sheet
A
Specific assessment criteria in a particular format, like human needs or functional patterns
7
Q
Focus charting
A
Client concerns and strengths the focus of care
DAR
Data action response
8
Q
Charting by exception
A
Only abnormal or significant findings are recorded
9
Q
Variance
A
Goal that is not met
10
Q
Source oriented record
A
Traditional. Separate departments
