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NUR 102 Chapter 16 (Documenting, Reporting, Conferring, and Using Informatics) Key Terms

Terms in this set (62)

1. Patient records also include diagnostic and therapeutic orders. Anyone reviewing the chart can find all the diagnostic studies ordered for the patient since admission.

2. Each Health care professional working with the patient has access to the patient's baseline and ongoing data and can see how the patient is responding to the treatment plan from day to day.

3. Quality process and Performance Improvement

"Documentation is the primary source of evidence used to continuously measure performance outcomes against predetermined standards" Thus, records might be reviewed to evaluate the quality of care patients have received and the competence of the nurses providing the care.

4. Researchers might study patient records, hoping to learn how best to recognize or treat identified health problems from the study or similar cases.

5. Information from record review often provides the data needed by administrative strategic planners to identify needs as well as the means and strategies most likely to address those needs. Record review might reveal both underused and overused services, patients with prolonged stays who require special assistance, etc

6. Health care professionals and students reading a patient's record can learn a great deal about the clinical manifestations of particular health problems, effective treatment, modalities, and factors that affect patient goal achievement.

7. Documentation allows reviewers to monitor health care practitioners' and the health care facility's compliance with standards governing the profession and provision of care.

8. Patient records are LEGAL documents that might be used as evidence in court proceedings. One in four malpractice suits are decided on the basis of the patient's record.

9. Patient records are used to demonstrate to payers that patients received the intensity and quality of care for which reimbursement is being sought.

10. Because all entries on records are dated. the record has value as a historical document. Years later, information concerning a patient's past health care might be pertinent