Chapter 7 deWit's Fundamental Concepts
and Skills for Nursing
case management charting - ANS Documentation that tracks variances from the clinical
pathway
Charting - ANS Documentation of the nursing process, treatment, and associated care.
Charting by Exception - ANS Documentation that focuses on deviations from predefined norms,
using preset protocols and standards of care.
Computer-assisted charting - ANS Documentation in which data are input via the computer.
computerized provider order entry (CPOE) - ANS The entering of provider orders into the
medical record via computer.
electronic health record (EHR) - ANS Health record entered into a computer's software program
that is updated via the computer.
focus charting - ANS Documentation that centers on the patient from a positive perspective;
this form of documentation has three components: data, action, and response.
medical record - ANS Paper or electronic record that contains all orders, test, treatments, and
care that occurred during the time a person was under the care of a health care provider.
PIE charting - ANS Method of documentation in which "P" means problem identification, "I"
means interventions, and "E" means evaluation.
problem-oriented medical record (POMR) charting - ANS Documentation that focuses on
patient status, emphasizes the problem-solving approach to patient care, and provides a
method for communicating what, when, and how things are to be done to meet the patient's
needs.
protocols - ANS Standard procedures.
source-oriented (narrative) charting - ANS Documentation that is organized by the "source" or
author of the documentation.
and Skills for Nursing
case management charting - ANS Documentation that tracks variances from the clinical
pathway
Charting - ANS Documentation of the nursing process, treatment, and associated care.
Charting by Exception - ANS Documentation that focuses on deviations from predefined norms,
using preset protocols and standards of care.
Computer-assisted charting - ANS Documentation in which data are input via the computer.
computerized provider order entry (CPOE) - ANS The entering of provider orders into the
medical record via computer.
electronic health record (EHR) - ANS Health record entered into a computer's software program
that is updated via the computer.
focus charting - ANS Documentation that centers on the patient from a positive perspective;
this form of documentation has three components: data, action, and response.
medical record - ANS Paper or electronic record that contains all orders, test, treatments, and
care that occurred during the time a person was under the care of a health care provider.
PIE charting - ANS Method of documentation in which "P" means problem identification, "I"
means interventions, and "E" means evaluation.
problem-oriented medical record (POMR) charting - ANS Documentation that focuses on
patient status, emphasizes the problem-solving approach to patient care, and provides a
method for communicating what, when, and how things are to be done to meet the patient's
needs.
protocols - ANS Standard procedures.
source-oriented (narrative) charting - ANS Documentation that is organized by the "source" or
author of the documentation.
