Documentation

• DOCUMENTATION


  Is the written, legal record of all pertinent interactions with the client.
• DOCUMENTING


  also known called as recording or charting
• Clinical Record


  also called chart, client record or patient record, is a formal, legal document that provides evidence of a client’s care.
• Traditional Client Record (Source-oriented record)


  • Each person or department/healthcare group keeps data on its own separate form.
  • Sections of the record (client’s chart) are designated for nurses, physicians, lab, x-ray personnel and others.
  • Notations are entered chronologically, with the most recent entry being nearest the front of the record.
• Narrative Charting


  a traditional part of the source-oriented record.
• Problem Oriented Medical Record (PMOR)


  Is organized around a patient’s problem rather than around sources of information.

  • Progress notes clearly focus on patient problems.