Documentation in Healthcare

Flashcards based on lecture notes about documentation in healthcare, including SOAP notes, narrative notes, HIPAA, and ethical considerations.

SOAP Note

An organizational structure that may be used for any type of note, including initial evaluations and progress notes.

Standardized Forms

Checklists, flow sheets, and standardized forms used to save time in documentation.

SOAP Notes Purpose

Helps standardize documentation among various healthcare professionals.

Narrative Notes

Notes that tend to be disorganized and subjective, unlike SOAP notes.

SOAP: Subjective (S)

Client's report of their problems, limitations, needs, and perception of treatment.

SOAP: Objective (O)

Health professional's observation of the client's performance and treatment provided.

SOAP: Assessment (A)

Health professional's analysis and interpretation of the subjective and objective sections.

SOAP: Plan (P)

Health professional's plan of what to do next, including frequency and duration of services.

DAP Notes

An adaption of SOAP notes where the D section contains both the A and O information

BIRP Notes

Behavior, Intervention, Response, Plan - a documentation format used in mental health settings

PIRP Notes

Problem/Purpose, Intervention, Response, Plan - a documentation format used in mental health settings

SIRP Notes

Situation, Intervention, Response, Plan - a documentation format used in mental health settings

HIPAA (1996)

Ensures employees can manage health benefits when changing jobs and establishes federal standards for PHI.

HIPAA Privacy Rule

Prevents unauthorized disclosure of clients' Protected Health Information (PHI).

AOTA Code of Ethics, Principle 3

The act of respecting the rights of the individual.

Completion of Notes

Notes that should be completed at work to avoid privacy violations.

Client

The group that owns the information documented in the health record.

Personal Health Record (PHR)

A way to organize and manage health information that may be scattered across various healthcare facilities and providers, maintained and controlled by the client.

FERPA (1974)

Guarantees parental access to student records and to permit access only to persons with legitimate reasons to view the records.

United States Department of Education

The department of the US government that funds educational institutions that must comply with FERPA regulations