Documentation Flashcards
Documentation/Charting
legal record of care
if name on it you are responsible
Primary purpose of documenting
communication
convey information
other purposes of documenting
tracks care given to individual
legally documents care you gave
tracks trends in outcomes for groups of clients
reflects whether we meet professional standards
maintains safety as a communication tool
uses to obtain payment for care
Patient Rights
patients have right to see and copy their health record
update info
get a list of disclosures
request a restriction on certain uses/disclosures
choose how to receive health information
DO NOT USE LIST
list of abbreviations, acronyms, symbols and dose designations that are not to be used
U, u
unit - mistaken for sero or the number 4 or cc
write unit
IU
international unit
mistaken for IV or 10
write international unit
Q.D., QD q.d. qd
QOD Q.O.D. q.o.d qod
daily
every other day
mistaken for each other - period after the q mistaken for I and the o mistaken for I
write daily or every other day
Trailing zero (X.0 mg)
lack of leading zero (.X)
decimal point is missed
write X mg
Write 0.X mg
MS
MS04 and MgSO4
can mean morphine sulfate or magnesium sulfate
confused for one another
write out morphine sulfate and magnesium sulfate
Repeat backs and clarifications
receiver of message repeats it back or reads it back
ask clarifying questions
clarify numbers and letters
