Chart Organization

1. Chart Organization KNR 279

2. 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.

3. 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

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

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

6. 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

7. 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

8. 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

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

10. 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

11. 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

12. 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

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

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

15. Advantages POMR • Data retrieval easier • Communication between disciplines is easier • Provides structure & organization

16. Disadvantages of POMR • Requires time to train staff