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Test 2 Documentation
Terms in this set (40)
What is documentation?
1) Written communication
2) Permanent record
What color pen should you use during documentation?
What are the 8 purposes of Documentation?
3) Care Planning
4) Quality assurance
What is the purpose of communication in documentation?
Provides client's progress to all members of healthcare team
What is Assessments role in documentation?
Provides the current health status of the client
What is the role of Care planning in documentation?
Comes from assessment data in the client record
What is the role of quality assurance in documentation?
Shows quality care being given as well as agency reimbursement
What is the role of Legal in Documentation?
They prove or disprove injuries or improper care
What is the role of research in Documentation?
Data gathered from records determine similarities in diseases
What is the purpose of education in documentation?
Assists healthcare team member and students understand diseases
What are the principles of Data Entry?
8) Computers in nursing
) Point of Care
What is Accuracy?
Observations clearly identified and spelled correctly
If you make an error how do you fix it in documentation?
Put a line through the error and initial
What is Completeness?
Information about the nursing progress must be complete
What is conciseness?
Brief and concise statements. Not long and drawn out
How could you use Objectivity for data entry?
Use direct quotes when possible, describe actual behaviors client exhibits
What is Organization in Data entry?
Chronologic flow of information about client care
How soon should something be documented?
As soon as possible after care is completed
What is Point of Care Data Entry?
Documenting at the bedside with computers
What are some sources of computers in documentation?
What can a PDA be used for?
Providing information for patient care
What is an EHR?
An area of nursing which focuses on technology in health care
What are some nursing progress notes?
5) Flow sheets
6) Charting by exception
What is a narrative?
A hand written account of the clients activities that includes date and time
What is SOAP?
A note that focuses on one problem and the nurses observations and interventions
Wat is PIE?
Incorporating the plan of care into a progress note
What is DAr
The focus system the focus of the note can be a problem of event
What is a Flow sheet?
Document the finding that fall outside of the norms or standards of care set by the institution
What is charting by exception?
Documenting the findings that fall outside of the norms or standards of care set by the institution
What is an incident report?
A report filled out upon occurrence of an unusual event, fall, or medication error
Who documents the incident report?
What type of language should you use in an incident report?
Non judgmental/ objective language
Do you write you made a mistake in the medical record?
Why is verbal communication used?
It maximizes client outcomes
What is the template for communication or report?
What are some examples of Verbal Communications in the healthcare setting?
1) Change of shift report
2) Report to primary care provider
What does the Change of Shift Report ensure?
That there is continuity of care that may be verbal or taped
How would you report to the Primary Care provider?
Call the physician to usually results from a change in the clients condition or for clarification or order
If the PCP gives orders over the phone what must be written out?
The orders as they would appear in that section of the chart
What is HIPPA?
Health Insurance Portability and Accountability Act introduced in 1996 to protect client's health information
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