ati documentation Flashcards
1
Q
documentation
A
- must be clear, accurate, considering, and accessible
- provide clear understanding and picture of the client
- allows interproffessional team to communicate w each other
2
Q
PIE
A
problem
intervention
evaluation
3
Q
SOAP
A
- subjective: symptoms
- objective: clinical impressions the health care provider sees, hears, touches, measures, or smells
- assessment: combines the subjective and objective info to arrive at a nursing home diagnosis
- plan: details steps to treat clients and suggests the need for consultation or additional testing to address clients needs
4
Q
source- oriented
A
- medical record is a traditional format for documenting within a medical record for all disciplines
- usually devided into specific sections such as history and physical, progress notes, nurses notes, lab reports, diagnostic testing
5
Q
focus charting
A
centers on specific health care problems and changes in condition, clients events and concerns
Data
Action
Response
(DAR)
6
Q
problem- oriented medical records (stages)
A
- developing a database (clients history, findings, diagnostics, and lab results
- identifying and numbering specific problems based on clients history. the date the problem is resolved is noted
- plan of action should be formulated for each problem
- there should be ongoing progress notes for each problem
7
Q
all charting should be done using fact acronym
A
factual
accurate
complete
timely
8
Q
correcting errors in doc
A
- keep original doc
- draw a single line thru entry and write error and initials
- record the date and time of when the correction was entered
- do not obscure the original entry with anything such as white out, black permanent marker…
- document the correct info
9
Q
late charting
A
- make sure to identify the entry as a late entry
- identify which event the late entry is for
- make sure all new entries are signed and dated
- identity which event or previous note the new note is referencing
- make sure there are no blank lines
10
Q
EHR
A
- systemic digitized doc system to improve client care
- provides comprehensive records
- means of communication
- accounts for every treatment, diagnosis, and provider visit for billing
11
Q
electronic doc guidelines
A
- never use anyone else’s login
- passwords must be strong, unique, changed freq
- log off when doc is complete
- never leave computer without logging off first
- computer monitor should be protected
- electronic sig- ensure name is correct and professional credentials are noted
12
Q
institute of safe medication practices
A
- devoted to preventing errors that occur within health care
- complies list of abbreviations that are appropriate to use w doc, helping to reduce confusion and errors