Documentation etc

Question 1

what are the 6 classes of registration

Answer 1

general
extended
non practicing
temporary
special assignment
emergency

Question 2

what is the difference between and EHR and an EMR

Answer 2

EHR: lifetime record of all health care encounters
EMR: legal record that describes a single encounter or visit

Question 3

name 5 common documentatin systems

Answer 3

narrative
problem oriented
source records
charting by exception
critical pathways

Question 4

Tort

Answer 4

civil wrong commited by one person to another causing injury or damage

Question 5

intentional tort

Answer 5

assault
battery
invasion of privacy
false imprisonment

Question 6

unintentional tort

Answer 6

negligence

Question 7

what is the narritive method of charting

Answer 7

describing everything basically

Question 8

what are source records

Answer 8

when each discipline records in a separate section

Question 9

what are problem oriented health care records

Answer 9

database, problem list, care plan and progress notes

Question 10

what does SOAP stand for

Answer 10

subjective
objective
assessment
plan

Question 11

what does SOAPIE stand for

Answer 11

subjective
objective
assessment
plan
interventin
evaluation

Question 12

what does PIE stand for

Answer 12

problem
intervention
evaluation

Question 13

what does SBAR stand for

Answer 13

situation
background
assessment
recommendation

Question 14

what does ISBARR stand for

Answer 14

identification
situation
background
assessment
recommendation
repeat back

Question 15

what are the 4 criteria for negligence

Answer 15

duty of care owed to the plaintiff
breach of duty of care by defendant
harm
harm due to breach of duty

Question 16

name 4 situations when emergency treatment can be provided immediately

Answer 16

communication barrier (language/disability)

reasonable efforts made but delay will prolong suffering and no evidence patient doesnt want treatment

incapable but substitute is available

incapaable/sub is not available and delay will put the person at risk

Question 17

who creates statue law

Answer 17

elective legislative bodies (ie parliament, or provincial/territorial legislatures)

Question 18

what is common law based on

Answer 18

precedent - previous decisions made by other judges in similar cases

Question 19

what are the 2 main sources of law

Answer 19

public law (statutes)
private law (civil and common law)

Question 20

what is a fiduciary relationship

Answer 20

a professional provides services that cause the recipient to trust in the specialized knowledge/integrity of the professional

Question 21

definition of assault

Answer 21

conduct that creates apprehension or fear of imminent harmful contact in a person

Question 22

definition of battery

Answer 22

intentional physical contact with a person without their consent

Question 23

is physical contact required for assault

Answer 23

nada

Question 24

what is criminal negligence

Answer 24

involves actions that reach the level of wanton or reckless disregard for the lives or safety of others

Question 25

what is the tort of negligence

Answer 25

breach of duty of care expected of a reasonably competent practitioner

Question 26

what is an advanced directive

Answer 26

mechanism enabling a mentally competent person to plan for a time when they may lack the mental capacity to make medical treatment decisions

Question 27

what is an instructional directive

Answer 27

spells out specific directions for governing care in more detail than youd find in a living will

Question 28

what is a proxy directive

Answer 28

appointing someone on your behalf as a health care agent to make treatment decisions for them

Question 29

what is a psychiatric advance directive

Answer 29

someone with mental health problems completes this type of directive during periods of mental stability

Question 30

living will

Answer 30

document in which the person makes an anticipatory refusal of life-prolonging measure during a future state of mental incompetence