Chapter Five

Question 1

Documentation

Answer 1

The act of recording pertinent medical information in a patients med rec, which may be handwritten, or charted electronically.

Question 2

Chart

Answer 2

Another word for documentation

Question 3

Electronic Health Record (EHR)

Answer 3

A written account of patient care that is accessed electronically

Question 4

Purposes of Documentation

Answer 4

-Communicate pertinent data that all heath-care team members need in order to provide continuity of care
-Provide a permanent record of medical diagnoses, nursing diagnoses, the plan of care, the care provided, and the patients response to that care
-Serve as a record of accountability for quality assurance, accreditation, and reimbursement purposes
-Serve as a legal record for both the patient and health-care provider

Question 5

How long does a facility have to keep a patients chart information on file?

Answer 5

5 years

Question 6

PIE

Answer 6

Problem
Intervention
Evaluation

Question 7

MDS

Answer 7

Minimum Data Sheets

Question 8

5 Documentation Mistakes that Carry Increased Risk of Malpratice

Answer 8

Failure to document assessment findings
Failure to document medications administered
Failure to document pertinent health history
Documenting on the wrong chart or MAR
Failure to accurately document physician’s orders

Question 9

Confidentiality

Answer 9

Maintenance of privacy by not sharing with third party any privileged or entrusted information