Types of Charting Flashcards

Questions and Answers

What does Narrative Charting refer to?

Story in chronological order (correct)

Summary of patient condition

Numerical charts of vital signs

Data analysis in graphical form

What does the acronym PIE stand for in PIE Charting?

Problem, Intervention, Evaluation

What does SOAP stand for in SOAP Charting?

Subjective data, Objective data, Assessment, Plan

What is the primary focus of Focus Charting®?

Client's concerns, problems, or strengths Signup and view all the answers

Charting by Exception involves documenting all patient findings.

False Signup and view all the answers

What are key components of FACT Documentation?

Flow sheets, Assessment with baseline data, Concise progress notes, Timely entries Signup and view all the answers

Study Notes

Types of Charting Flashcards

Narrative Charting: Involves a chronological "story" that tracks a patient's changing status; can result in lengthy and disorganized entries.
PIE Charting: Stands for Problem, Intervention, Evaluation. Used exclusively in problem-oriented charting and helps establish an ongoing plan of care.
SOAP Charting: Represents Subjective, Objective, Assessment, Plan. Some variations include IER, adding Intervention, Evaluation, and Revision to the format.
Focus Charting®: Centers on the client's concerns or strengths, structured in three columns:
- Time and date
- Focus or problem addressed
- DAR format: Data, Action, Response.
Charting by Exception: Only records significant findings or deviations from normal, designed to streamline the charting process and save time. Utilizes preprinted forms and checklists, but risks inadvertent omissions.
FACT Documentation: Features flow sheets that tailor specific services, includes assessments with baseline data, concise progress notes, and emphasizes timely entries.

Description

This quiz covers various types of charting used in healthcare documentation, including Narrative Charting, PIE Charting, and SOAP Charting. Each type is defined and its purpose in patient care is explained. Enhance your understanding of charting methods essential for effective medical practice.