Chart Organization KNR 279

2 Types of Documentation  Program management KNR 278 WPO, specific program plans, policy & procedures, risk management plan, etc.  Client management KNR 279 Assessment, treatment plan, progress notes, discharge plan, etc.

RATIONALE FOR DOCUMENTATION  Assurance of quality services  Facilitate communication among staff  Professional accountability & self- regulation  Compliance with administrative requirements  Provision of data for QI and efficacy research

PATIENT RECORDS/CHART ORGANIZATION  Common methods Source-oriented recordkeeping/ narrative format Problem-oriented medical record (POMR) Others

SOURCE-ORIENTED / NARRATIVE  Each profession keeps data separate from other professionals  Few guidelines for formatting  Notes are written in narrative style

SOURCE-ORIENTED / NARRATIVE  Advantages Easy to write Notes are in chronological order Progress is easy to follow Each discipline’s entries are easy to locate Flexible charting system Can be used in any setting

SOURCE-ORIENTED / NARRATIVE  Disadvantages Variety of notes Notes can be lengthy Difficult to track reports of multiple disciplines Hard to retrieve information Inexperienced writers may not focus their notes & include vague or irrelevant information Takes time

PROBLEM-ORIENTED  Chart organized by client problems rather than by each discipline  More coordinated effort  Format stays the same regardless of agency or professional group

PROBLEM-ORIENTED  5 components Database or initial assessment results Client problem list Initial treatment plan Progress notes Discharge summary

DATABASE  Chief complaint or reason for admission  Personal & family history  Medications & allergies  Employment, etc.  May be completed by admitting physician or admission personnel  Detailed assessment data gathered by each discipline

PROBLEM LIST/NEEDS  Conditions or situations that the patient can not readily handle alone and requires interventions from members of the team  Not each problem will be addressed by every member  May need to educate about leisure needs  Each problem is numbered and chart organized by problems  Problems are prioritized

INITIAL PLAN  Treatment plan, IEP, care plan, etc.  Goals and objectives  Plans for additional data collection  Specific programs  Staff and client responsibilities  Facilitation styles  Frequency & duration of program involvement  Schedule for reevaluation of plan

PROGRESS NOTES  Shows progression, regression, or no change related to goals  SOAP format  S-----subjective data  O-----objective data  A-----analysis  P-----plan

DISCHARGE SUMMARY  Summary of client’s treatment  Major goals achieved  Services received  Remaining problems  Plans for follow-up

Advantages POMR  Data retrieval easier  Communication between disciplines is easier  Provides structure & organization

Disadvantages of POMR  Requires time to train staff