RCTX 3254 Test 2 Study Guide

A structured charting system that uses a four-part format: Subjective, Objective, Assessment, and Plan. In this system, the clinician documents the patient's subjective report of symptoms, their objective observations, their assessment of the patient's condition, and their plan for treatment.

A structured charting system that uses a four-part format: Behavior, Intervention, Response, and Plan. BIRP allows clinicians to document patient behaviors, interventions, and responses to treatment in a concise and organized way.

A type of charting that focuses on the patient's needs and concerns. Uses a problem-oriented approach, organizing documents in a way that prioritizes the patient's key issues. Clinical data is organized around main concepts, providing a holistic view of the patient's situation.

A method of documentation that uses a chronological narrative style to describe patient encounters. Provides a complete and detailed account of a patient's progress, care, and interactions with providers.

The process of observing and recording an individual's behavior in a structured and systematic way. It involves defining specific behaviors of interest, selecting appropriate observation methods, and recording observations accurately and objectively.

The ability to pay full attention to the client and show a genuine interest in what they have to say.

A discharge summary is a comprehensive report that provides a summary of a patient's hospitalization, treatment, and progress, and outlines the patient's discharge plans. It communicates vital information to other healthcare providers involved in the patient's post-discharge care.

A structured assessment tool used to measure a patient's functional independence in activities of daily living. It evaluates a patient's ability to perform various tasks, such as dressing, bathing, and eating.