Week 6 Flashcards
(10 cards)
0
Q
When is source-oriented documentation used?
A
Disciplines chart on separate areas
Data scattered
1
Q
List the various forms of documentation
A
Source-oriented Problem-oriented Charting by exception EHR Narrative PIE SOAPIER Focus FACT system
2
Q
When is problem-oriented documentation used?
A
Organized around patient problems
All disciplines chart and add to nursing care plan - allows greater collaboration
3
Q
When is charting by exception used?
A
Charting only significant findings/exceptions to norms
4
Q
When is EHR used?
A
Drop down boxes with free text, used for charting exceptions
5
Q
When is narrative charting used?
A
Chronological format/ timeline
6
Q
When is PIE charting used?
A
Problem/intervention/evaluation
7
Q
When is SOAPIER used?
A
Subjective Objective Assessment Plan Evaluation Revision
8
Q
When is focus documentation used?
A
Data
Action
Response
9
Q
When is FACT system documentation used?
A
Documenting exceptions to the norm
