Healthcare Team Communication: Documenting and Reporting Flashcards
1
Q
Describe the importance of timely, accurate communication in healthcare
A
Delayed, inaccurate, or absent communication can subject the patient to serious risks or delayed recovery.
2
Q
Purposes of the Health Record
A
Communication
Assessment
Care Planning
Legal Document
Research
Education
3
Q
Principles of Documentation
A
Confidential
Accurate
Concise and Complete
Organized and Timely
4
Q
SOAP Note
A
Subjective
Objective
Assessment
Plan
5
Q
Plan of Care (POC)
A
Nursing Diagnosis (or problems)
Goals
Outcome Criteria
Intervension
Evaluation
At admission and revised to reflect pt’s condition
6
Q
SBAR
A
Situation
Background
Assessment
Recommendation
