Types of Medical Records and Documentation Formats

Vocabulary flashcards covering medical record types, documentation formats, verbal orders, hand-off reporting, and the SBAR framework.

Written Medical Record

Also known as Paper Charting.

Electronic Health Records (EHR)

Includes all the information from inpatient and outpatient episodes of health care from one or more settings.

Electronic Medical Records (EMR)

Captures one episode of care.

CPOE (Computerized Provider Order Entry)

Allows MD to enter orders specifically for departments.

PIE

Documentation format standing for Problem, Intervention, Evaluation.

APIE

Documentation format standing for Assessment, Problem, Intervention, Evaluation.

SOAP

Documentation format standing for Subjective data, Objective data, Assessment, Plan.

SOAPIER

Documentation format standing for Subjective data, Objective data, Assessment, Plan, Intervention, Evaluation, Revisions to plan.

DAR

Documentation format standing for Data, Action, Response.

CBE

Charting by Exception.

Narrative Charting

Chronologic data recorded in progress notes, not organized, which can stand alone or be complimented by other forms of charting.

Flowsheets

Documentation tools designed to reduce documentation time, generally including routine care or observations such as V/S, I&O, and meds.

Verbal or Telephone Orders

Orders often limited to emergency situations that must be taken by an RN who repeats the order verbatim, enters it into the EMR, documents date, time, physician's name, and RN signature, and requires physician co-sign within a defined time period.

Hand-off Reports

Passing patient-specific information from one caregiver to another (oral, written, recorded, or printed) to promote continuity of care and patient safety.

Sentinel Events

Adverse safety occurrences that could happen as a result of an incomplete handoff report.

SBAR

A standardized reporting format consisting of Situation, Background, Assessment, and Recommendation.

SBAR - Situation

Briefly describes the current situation or issue (what is happening right now).

SBAR - Background

Provides relevant background info about the patient and what circumstances led to this situation.

SBAR - Assessment

Shares clinical assessment or findings (subjective/objective info) regarding what you think the problem is.

SBAR - Recommendation

States your recommendation or what you need to correct the problem.