documenting & reporting Flashcards
1
Q
the written or electronic legal record of al pertinent interactions w/ pt; assessing, diagnosing, planning, implementing, evaluating
A
documentation
2
Q
all info written about patients on paper, spoken aloud, saved on computer
A
confidentiality
3
Q
- see copy of health care record
- update health record list of disclosures
- request a restriction on certain uses or disclosures
- choose how to receive health info
A
pt rights
4
Q
repeat back for accuracy, sign orders w/ name, title, pager number. date & time orders signed
A
verbal orders
5
Q
ISBARR
A
identity/introduction, background, assessment, recommendation, read back of orders/response
6
Q
document occurrence of anything out of the ordinary that results in, or has the potential to harm a patient, employee, or visitor; used for quality improvement
A
incidence report
7
Q
T/F: the RN can inform the family of results
A
F –> RN can only explain what result mean
