Documentation System Definitions
ALERT A charting system used primarily in long-term care in which the patient's chart is tagged to indicate that special charting procedures/precautions need to be initiated and followed for a specified time.
CBE Acronym for C harting B y E xception, a system for documentation that eliminates the need to chart repetitious findings and tasks. The health care provider uses specially designed admission history and flow sheets that highlight important findings and trends. Only significant findings or exceptions to established standards of care and protocols are documented in the progress notes.
CLINICAL PROGRESSION A critical path that has been enhanced by the addition of (1) nursing diagnosis, (2) intermediate and discharge goals, and (3) variance tracking. This type of plan is usually used for longer hospital stays not requiring critical care.
CORE A documentation system designed to support the nursing process. Key elements include database, care plans, flow sheets, progress notes, and discharge summaries. Progress notes use a three-column format and are organized using patient D atabase; A ction of the health care provider; and E valuation of patient outcome.
CRITICAL PATH A cause-and-effect grid that outlines usual interventions by health care providers against a timeline for a case type (diagnosis-related group) or otherwise defined homogeneous patient population. This type of plan is usually used in cases requiring critical care.
DAR Acronym for the organizing structure for writing progress notes using Focus Charting©. Each Focus entry includes D atabase describing the current patient condition; A ction taken by the health care provider; and patient R esponse or outcome to the intervention.
FACT Acronym for a documentation system including these key elements: F lowsheets for specific patient populations; standardized A ssessment parameters printed on the chart form; C oncise integrated progress notes; and T imely entries by health care providers at the time care is given.
FOCUS CHARTING© Trademark title for a three-column format for organizing the progress notes in the patient record. The FOCUS column serves as an index. The body of the note is organized by identifying the DATAbase describing the current patient condition; ACTION taken by the health care provider; and patient RESPONSE to or outcome of the intervention.
PIE Acronym for a process-oriented documentation system. The progress notes in the patient record use (P) to define the particular P roblem; (I) to document I ntervention; and (E) to E valuate the patient outcome. PIE charting integrates care planning with progress notes.
POMR Acronym for P roblem- O riented M edical R ecord, a method of establishing and maintaining the patient's medical record so that problems are clearly stated. These data are kept in the front of the chart and are evaluated as frequently as indicated with respect to recording changes in the patient's problems as well as progress made in solving the problems. Use of this system may bring a degree of comprehensiveness to total patient care that might not be possible with conventional medical records. Internists, family practitioners, and pediatricians use the POMR system.
SOMR Source-Oriented Medical Record; groups formation according to its source: laboratory work, x-rays, examinations, consultations.
SOAP Acronym for an organized structure for keeping progress notes in the chart. Each entry contains the date, number, and title of the patient's particular problem, followed by the SOAP headings: S ubjective findings; O bjective findings; A ssessment, the documented analysis and conclusions concerning the findings; and P lan for further diagnostic or therapeutic action. If the patient has multiple problems, a SOAP entry on the chart is made for each problem.
SOAPIER Adds to the SOAP headings listed above: documentation of I ntervention implemented to solve the identified problem; E valuation of the effectiveness of the intervention; and care plan R evisions indicated.
VARIANCE A task or outcome that does not occur as described or within the time frame identified on a critical path or clinical progression.