Fundamentals Exam 3 Review
Chapter 7-Documention
Purposes of documentation
Written record
Covers you in court/lawsuit
Legal document
Insurance purposes/ for funding
Shows progress
Communication between workers
Document as care is given
The Medical Record (The Chart)
The facility owns the record not the pt
If pt wants any records they need to go through medical records
Confidential
Source oriented charting VS. Focus Charting
Source oriented- from beginning to end (narrative charting) information is
straight from pt (done on admission, detailed and in depth)
o Advantage- chronological so easy to find information
o Disadvantage- very long and time consuming, when dr comes doesn’t read
everything so they can miss important information
Focus- just focuses on the specific problem at hand
o Advantage-short, focus on the problem
o Disadvantage-not enough information about the pt
Charting by exception- nursing homes, don’t chart every
pt for everything, only if there is a chang
Advantage-saves time
Disadvantage-forgets to chart
This study source was downloaded by 100000900231380 from CourseHero.com on 07-31-2025 07:47:00 GMT -05:00
https://www.coursehero.com/file/250205221/Fundamentals-Exam-3-Reviewdocx/
, Computer assisted charting- electronic health record
Advantage- legible, time and date automatic and can be done at bedside
Disadvantage- if internet or electricity goes out no access and very
expensive
Error in documentation
Cross out with one line
Initial
Write “error”
Date of error
But you would ultimately follow agency policy
Chapter 8- Communication
Factors affecting communication
Culture
o Asian and American Indian- want personal space (2 ½-4 ft) and avoid eye
contact
Language
o Get interpreter
Obtaining feedback
Therapeutic communication technique
Use open ended questions
o “tell me more”
o Make sure it answers the question
If pt is upset/angry
o Acknowledge the pt feelings
ex. “I can see how you feel that way”
ex. “it must be very difficult for you”
If pt is crying
This study source was downloaded by 100000900231380 from CourseHero.com on 07-31-2025 07:47:00 GMT -05:00
https://www.coursehero.com/file/250205221/Fundamentals-Exam-3-Reviewdocx/
Chapter 7-Documention
Purposes of documentation
Written record
Covers you in court/lawsuit
Legal document
Insurance purposes/ for funding
Shows progress
Communication between workers
Document as care is given
The Medical Record (The Chart)
The facility owns the record not the pt
If pt wants any records they need to go through medical records
Confidential
Source oriented charting VS. Focus Charting
Source oriented- from beginning to end (narrative charting) information is
straight from pt (done on admission, detailed and in depth)
o Advantage- chronological so easy to find information
o Disadvantage- very long and time consuming, when dr comes doesn’t read
everything so they can miss important information
Focus- just focuses on the specific problem at hand
o Advantage-short, focus on the problem
o Disadvantage-not enough information about the pt
Charting by exception- nursing homes, don’t chart every
pt for everything, only if there is a chang
Advantage-saves time
Disadvantage-forgets to chart
This study source was downloaded by 100000900231380 from CourseHero.com on 07-31-2025 07:47:00 GMT -05:00
https://www.coursehero.com/file/250205221/Fundamentals-Exam-3-Reviewdocx/
, Computer assisted charting- electronic health record
Advantage- legible, time and date automatic and can be done at bedside
Disadvantage- if internet or electricity goes out no access and very
expensive
Error in documentation
Cross out with one line
Initial
Write “error”
Date of error
But you would ultimately follow agency policy
Chapter 8- Communication
Factors affecting communication
Culture
o Asian and American Indian- want personal space (2 ½-4 ft) and avoid eye
contact
Language
o Get interpreter
Obtaining feedback
Therapeutic communication technique
Use open ended questions
o “tell me more”
o Make sure it answers the question
If pt is upset/angry
o Acknowledge the pt feelings
ex. “I can see how you feel that way”
ex. “it must be very difficult for you”
If pt is crying
This study source was downloaded by 100000900231380 from CourseHero.com on 07-31-2025 07:47:00 GMT -05:00
https://www.coursehero.com/file/250205221/Fundamentals-Exam-3-Reviewdocx/
