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Nursing Essentials > Documentation > Flashcards

Documentation Flashcards

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1
Q

What is health care documentation

A

Any information about a patient

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2
Q

Does paperwork get scanned in electronically

A

yes

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3
Q

What is the purpose of health care documentation

A

Facilitation of information FLOW that supposrts CONTINUITY, QUALITY, and SAFETY of care

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4
Q

What is the joint commission

A

Accrediting organization that will come ON-SITE and if you are not accredited then some INSURANCES will not let pts go there

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5
Q

What is the centers for medicare and Medicaid services (CAD)

A

If you are not accreded then they will not pay for medicare and medicaid

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6
Q

What is the ANA- standards of professional practive

A

Standards just for nurses

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7
Q

What should you know about the medical record

A

DATA, RESEARCH, REIMNURSEMENT, CONTINUITY, QUALITY, EDUCATION, REGULATIONS

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8
Q

How many people will read your medical records

A

many

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9
Q

What are the important things regarding nursing documentation

A

FACTUAL, NON-JUDGMENTAL, TIMELY, common TERMIONLOGY, shows what you DID

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10
Q

What is narative charting

A

Describing the situations

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11
Q

What is some examples of formatted charting

A

PIE, SOAP

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12
Q

What is the most common formatted charting

A

SOAP

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13
Q

What type of formatted charting only charts the exceptions

A

CBE

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14
Q

What can documentation do when there is legal counsel

A

PREVENT a case or give you PROTECTION

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15
Q

What do you do if you make a written mistake

A

Cross out with a SINGLE line, write “error”, and initial

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16
Q

What do you do if you make an electronic mistake

A

Make a comment

17
Q

What did the 2009 American recovery and reinvestment act do

A

Mandated the use of EHR by 2014

18
Q

What is computerized provider order entry and what did it do

A

Doctors put their orders in electronically, prevents interpretation and decreases the possibility for error

19
Q

What should you know about verbal orders

A

EMERGENCIES, only taken by a RN, REPEAT, DOCUMENT, CO-SIGN by provider

Nursing Essentials (5 decks)

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