Documentation Flashcards

1
Q

What is the purpose of a legal record?

A
  • verifies need for care
    -nurses held accountable for actions
    -can be used in court
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is a source record?

A

separate section for each discipline

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is a clinical/critical pathway?

A

only charts deviations from the pathway

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

When taking notes what is the DAR method?

A

Data, Action, Response

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

When taking notes what is the PIE method?

A

Problem, Intervention, Evaluation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

When taking notes what is the SOAP method?

A

Subjective, Objective, Assessment, Plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What can be included on a omitted care document?

A

incident reports

How well did you know this?
1
Not at all
2
3
4
5
Perfectly