• communication
• auditing agents
• reimbursements
• research
• education
• legal reasons

• Source-oriented record
• problem-oriented medical record
• PIE
• Focus Charting
• computerized documentation
• case management

• Traditional client record.
• Each department makes notations in a separate section or sections of the client's chart

_{Emphasis on the patient’s problems.}

• database
• problem list
• plan of care
• progress notes

• subjective data
• objective data
• assessment
• plan
• (Intervention
• Evaluation)

• A record of the progress of specific or specialized data such as :
• vital signs,
• fluid balance
• routine medications

• Provide clear, concise, accurate information
• Document: when, who made call, who was called, to whom info was given, what info was given, what info was received

• Incident not consistent with routine care & safety issues
• Record what actually happened
• Do not record in medical record that incident report was filled out
• Used in quality improvement programs to monitor trends

• Descriptive, objective data about what you
• see, hear, feel, or smell
• Result of direct observation and measurement
• NO seems, appears, apparently
• Subjective data – document patient’s exact words in quotation mark

• Paragraph form, long, time consuming
• Information can be organized in any logical manner
• Reflect progress toward goals

• Preinteraction phase
• Introductory phase
• Working phase
• Termination phase

• reviews pt information
• considers areas of concern
• develops plan for interaction

• Open the relationship
• Clarify problem
• Structure and formulate contract

• Explore and understand thoughts and feelings associated w/problem
• Facilitate and take action

• Accept feelings of loss
• End relationship without feelings of anxiety or dependence

• Sender
• Channel
• Receiver
• Feedback

• Cognitive knowledge
• Affective disposition (emotions)
• Psychomotor (skills)

• The main idea of what the client has said is repeated
• Lets the client know whether or not an expressed statement has been understood and gives him or her the chance to continue or clarify if necessary

• Sit facing the client
• Observe your open posture
• Lean forward toward the client
• Establish Eye contact
• Relax.