TERMIUM Plus®

The Government of Canada’s terminology and linguistic data bank.

DOCUMENTATION RESOLUTION PROBLEME [1 record]

Record 1 2004-12-07

English

Subject field(s)
  • Medical and Hospital Organization
DEF

A structured method of documentation that allows the nurse to consider interventions and patient responses, as well as observations of the patient.

CONT

The two-page focus charting outline is most appropriate for a rehabilitation unit. Functional activities such as mobility and activities of daily living are emphasized, while the cardiovascular, respiratory, and gastrointestinal areas are grouped together under the "physical" focus heading. When used correctly, focus charting is complete, orderly, and effective. It meets professional and legal standards and the requirements of third-party payers. Utilization reviewers easily can spot progress, or lack of it, after a few days. Research and audit information can be retrieved readily using the focus headlines. The progress notes are clear and easy for other nurses and other disciplines to review. This promotes communication among the entire healthcare team and ultimately promotes continuity of care. Focus charting is efficient and effective when used by nurses to focus on patient problems and strengths.

French

Domaine(s)
  • Organisation médico-hospitalière
OBS

consignation au dossier par problème; documentation par résolution de problème; dossier orienté par problèmes: termes retenus par le réseau Entraide Traduction Santé.

Spanish

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