Documentation Flashcards
documentation describes what (3)
-the patient
-the patient’s health
-care and services provided
standards of documentation are established by health organization and should agree with ________
The Joint Commission’s standards
_______ is the legal documentation of care provided to a patient
medical record
(often used as evidence in a litigation)
what must every note in a medical record include
date, time, signature with credentials
what are traditional guidelines for hand-written medical records
black ink; include date, time, signature; no blank spaces
_______ = a record of one episode of care
EMR (electronic medical record)
______= longitudinal record of health
EHR (electronic health record)
(required for each person by the govt)
the EHR includes documentation from what two sources
inpatient and outpatient
RNs are responsible to reviewing documentation by _______ for all patients in their care
unlicensed assistive personnel (UAP)
documentation is guided by the five steps of the nursing process, what are those steps
-assessment
-care plan
-interventions
-patient outcomes
-assessment of patient’s ability to manage
who can patient information be shared with
individuals who have a need and right to know
______:real-time process of passing patient-specific information from one caregiver to another or among interdisciplinary team members to ensure continuity of care and patient safety
handoff
when taking a verbal or telephone order what must be done
-RN must repeat the order verbatim
-enter the order into the system
-document order as verbal/phone
-include date, time, physician’s name, RN signature
(may require the physician to cosign the order)
when an unusual or unexpected event occurs _____ must be completed
incident report
(not a part of the medical record)
an incident report must be documented ____ to ensure accuracy
immediately
