Chart Organization
KNR 279
2 Types of Documentation
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Program management
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KNR 278
WPO, specific program plans, policy &
procedures, risk management plan,
etc.
Client management
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KNR 279
Assessment, treatment plan, progress
notes, discharge plan, etc.
RATIONALE FOR
DOCUMENTATION
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Assurance of quality services
Facilitate communication among
staff
Professional accountability & selfregulation
Compliance with administrative
requirements
Provision of data for QI and efficacy
research
PATIENT RECORDS/CHART
ORGANIZATION

Common methods

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Source-oriented recordkeeping/
narrative format
Problem-oriented medical record
(POMR)
Others
SOURCE-ORIENTED /
NARRATIVE
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Each profession keeps data
separate from other professionals
Few guidelines for formatting
Notes are written in narrative style
SOURCE-ORIENTED /
NARRATIVE
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Advantages

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Easy to write
Notes are in chronological order
Progress is easy to follow
Each discipline’s entries are easy to
locate
Flexible charting system
Can be used in any setting
SOURCE-ORIENTED /
NARRATIVE

Disadvantages
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Variety of notes
Notes can be lengthy
Difficult to track reports of multiple
disciplines
Hard to retrieve information
Inexperienced writers may not focus
their notes & include vague or
irrelevant information
Takes time
PROBLEM-ORIENTED

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Chart organized by client problems
rather than by each discipline
More coordinated effort
Format stays the same regardless of
agency or professional group
PROBLEM-ORIENTED

5 components
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Database or initial assessment results
Client problem list
Initial treatment plan
Progress notes
Discharge summary
DATABASE
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Chief complaint or reason for
admission
Personal & family history
Medications & allergies
Employment, etc.
May be completed by admitting
physician or admission personnel
Detailed assessment data gathered
by each discipline
PROBLEM LIST/NEEDS
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Conditions or situations that the patient can
not readily handle alone and requires
interventions from members of the team
Not each problem will be addressed by
every member
May need to educate about leisure needs
Each problem is numbered and chart
organized by problems
Problems are prioritized
INITIAL PLAN

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Treatment plan, IEP, care plan, etc.
Goals and objectives
Plans for additional data collection
Specific programs
Staff and client responsibilities
Facilitation styles
Frequency & duration of program
involvement
Schedule for reevaluation of plan
PROGRESS NOTES

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Shows progression, regression, or
no change related to goals
SOAP format
S-----subjective data
O-----objective data
A-----analysis
P-----plan
DISCHARGE SUMMARY
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Summary of client’s treatment
Major goals achieved
Services received
Remaining problems
Plans for follow-up
Advantages POMR

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Data retrieval easier
Communication between disciplines
is easier
Provides structure & organization
Disadvantages of POMR

Requires time to train staff