What does chart by exception mean?

Charting by Exception Framework

When a healthcare provider charts by exception, it means that only exceptions to these baseline findings would be charted. If nothing was charted, the patient’s status is assumed to match the baseline. … Providers who find this in the patient’s exam would not need to chart this.

Which is an aspect of charting by exception quizlet?

Charting by exception simplifies nursing documentation by eliminating the need to document routine, stable patient information. It should be used in conjunction with flowsheets and brief narrative charting to ensure comprehensive documentation.

Which of the following is documented in the patient’s chart?

A medical chart is a complete record of a patient’s key clinical data and medical history, such as demographics, vital signs, diagnoses, medications, treatment plans, progress notes, problems, immunization dates, allergies, radiology images, and laboratory and test results.

What are the 5 C’s of charting?

Client’s Words, Clarity, Completeness, Conciseness, Chronological Order and Confidentiality.

Which abbreviation can be used when documenting a patient’s care in the medical record?

Unsourced material may be challenged and removed. The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient’s chart, along with other common formats, such as the admission note.

Which section of the traditional source record does the nurse?

Which section of the traditional source record does the nurse use to record this information? RATIONALE: Demographic information includes the legal name, identification number, gender, age, birth date, marital status, and occupation of the patient.

How many Cs are there to charting?

The Six C’s of charting.

Which of the following terms is one of the six Cs of charting?

Medical office administrative assistants should memorize these six C’s to maintain accurate patient medical records. They are client’s words, clarity, completeness, conciseness, chronological order, and confidentiality.

What are the C’s of charting?

C-charts show how the process, measured by the number of nonconformities per item or group of items, changes over time. Nonconformities are defects or occurrences found in the sampled subgroup. … For example a scratch, dent, bubble, blemish, missing button, and a tear would all be nonconformities.

What are the 6 C’s of medical charting and what does each mean?

Terms in this set (6)

Client’s words. Use direct quotation of the client rather than your interpretation. Clarity. Use measurement and accepted medical terminology. Completeness.

Which of the following is one of the six Cs of charting quizlet?

Which of the following is one of the six Cs of charting? order, and confidentiality.

When performing a physical exam the abbreviation Perrla is used to describe what part’s of the body?

The PERRLA (Pupils Equal, Round, React to Light and Accommodation) acronym is a useful tool to use. A change in pupillary response, such as unequal or dilated pupils can provide a warning sign of increasing intracranial pressure (ICP) (Anness & Tirone, 2009).

What are the five Cs in medical record documentation?

Terms in this set (5)
  • Client. The pt’s own words must be used.
  • Clarity. Must be achieved when recording information using proper spelling & medical terminology & abbreviation.
  • Completeness. Is essential for all information recorded in a medical chart.
  • Chronological. Order of information.
  • Confidentiality.

What is the approved medical abbreviation for family history quizlet?

What is the approved medical abbreviation for family history? FH. Medical records that are compiled according to the originator of the data are called: source-oriented medical records.

What is an examination and review of patient records?

Audit. Examination and review medical records for accuracy.

What are the four C’s of medical records?

The 4 C’s are based on what patients want in their doctors: competency, communication skills, compassion, and convenience.

What are some guidelines for effective charting?

Terms in this set (6)
  • Conciseness can save time and space.
  • Confidentiality to protect the patient’s privacy.
  • Client’s words should be recorded exactly.
  • Completeness is required.
  • Chronological order and date all entries.
  • Clarity is essential when describing the patients condition.

What are five characteristics of good medical documentation?

6 Key Attributes of a Medical Record
  • Accuracy of the medical record. The accuracy of the data refers to the correctness of the data collected. …
  • Accessibility of the medical record. …
  • Comprehensiveness of data. …
  • Consistency of information in the medical record. …
  • Timeliness of information. …
  • Relevancy of the medical records.