Recording and Reporting

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Across
  1. 1. method of recording the client’s progress under the headings of problem, intervention, and evaluation
  2. 5. process of writing information
  3. 7. an exemption whereby an agency can release private health information without a client’s prior authorization
  4. 8. style of documentation generally used in source-oriented records
  5. 11. time based on a 24-hour clock
  6. 12. binder or folder that enables the orderly collection, storage, and safekeeping of a client’s medical records
  7. 13. records organized according to the source of information
  8. 15. repetitious entry of the same information in the medical record
  9. 16. written collection of information about a person’s health problems, the care provided by health practitioners, and the progress of the client
  10. 17. modified form of SOAP charting
  11. 19. visits to clients on an individual basis or as a group
  12. 22. documentation method in which only abnormal assessment findings or care that deviates from the standard is charted
  13. 23. model for effective communication identifying Situation, Background, Assessment, and Recommendation
  14. 26. documentation style more likely to be used in a problem-oriented record
  15. 27. process of entering information
  16. 28. process of promoting care that reflects established agency standards
  17. 29. time based on two 12-hour revolutions on a clock
  18. 30. form of documentation in which the nurse indicates with a check mark or initials that routine care has been performed
  19. 31. form of documentation that contains sections for recording frequently repeated assessment data
Down
  1. 2. legislation that sets national standards for the security of health information, ensures that an individual’s electronic, paper, or oral health information is protected
  2. 3. records organized according to the client’s health problems
  3. 4. process of promoting care that reflects established agency standards
  4. 6. portions or isolated pieces of information necessary for an immediate purpose
  5. 9. quick reference for current information about the client and the client’s care
  6. 10. documenting client information with a computer
  7. 14. discussion between a nurse from the shift that is ending and personnel coming on duty
  8. 18. inspectors who examine client records
  9. 20. process of promoting care that reflects established agency standards
  10. 21. process of entering information
  11. 24. collection, storage, retrieval, and sharing of recorded data
  12. 25. written list of the client’s problems, goals, and nursing orders for client care