Narrative Note
A written description of observations and actions. It provides context and detail.
Objective Data
Information that is measurable or observable. It includes vital signs and physical findings.
Subjective Data
Information reported by the person. It includes feelings symptoms and concerns.
Charting by Exception
A method where only abnormal findings are documented. It saves time while highlighting concerns.
Flow Sheet
A form used to record routine measurements. It helps track trends over time.
SOAP Note
A structured format for documentation. It includes subjective objective assessment and plan sections.
Late Entry
A documentation entry made after the event occurred. It must be clearly labeled to maintain accuracy.
Addendum
Additional information added to a previous note. It clarifies or updates documentation.
Continuity of Care
The consistent and coordinated delivery of services. Documentation supports communication across providers.
Legal Record
The official record of care provided. It can be used in investigations or court.
Timeliness
The requirement to document care promptly. It ensures accuracy and supports decision making.
Accuracy
The requirement to record information truthfully and precisely. It protects the integrity of the record.
Confidentiality
The obligation to protect personal information. It applies to all documentation.
Abbreviation
A shortened form of a word used for efficiency. It must be standardized to avoid confusion.
Signature
A mark identifying the person who documented. It may be electronic or written.
Care Summary
A brief overview of care provided. It supports transitions and communication.
Progress Note
A record of changes and responses to care. It helps track improvement or decline.
Incident Report
A document describing an unusual event. It is used for quality improvement not punishment.
Data Integrity
The accuracy and reliability of information. It is essential for safe care.
Documentation Standard
A rule or guideline for recording information. It ensures consistency across staff.