Chapter 8-Principles Of Effective Documentation Flashcards
1
Q
Patient care report (PCR)
A
A document that provides details about a patients condition, history, and care as well as information about the event that caused the illness or injury
2
Q
Continuity of care
A
Refers to how each provider who is assuming care for a patient is properly informed of the patients progression, so he can watch for trends and continue effective treatment
3
Q
Minimum data report
A
The minimum information required by the department of transportation (DOT) standards for each patient, typically, applies to only 911 calls
4
Q
Electronic documentation
A
Refers to technology such as laptop computers, electronic tablets, and cellular phones, and their use to document patient condition and care
