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NSG2113 - nursing science > Lecture 8 - Documentation and Reporting > Flashcards

Lecture 8 - Documentation and Reporting Flashcards

1
Q

Purpose of Documentation

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2
Q

Communication and Care Planning

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3
Q

Legal Documentation

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4
Q

Funding and Resoure Management

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5
Q

Auditing and Monitoring (Quality of Care)

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6
Q

Research

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7
Q

Education

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8
Q

Electronic Health Records

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9
Q

Confidentiality

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10
Q

Personal Information Protection and Electronic Documents Act (PIPEDA)

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11
Q

Guidelines for Quality Documentation and Reporting (6)

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12
Q

Factual Documentation

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13
Q

Accurate Documentation

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14
Q

Complete Documentation

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15
Q

Current Documentation

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16
Q

Organized Documentation

17
Q

Documentation Compliant with Standards

18
Q

Types of Documentation

19
Q

Narrative Documentation

20
Q

Problem-Oriented Health Care Record

21
Q

Source Records

22
Q

Charting by Exception

23
Q

Critical Pathways/ Care Maps

24
Q

Documentation as Legal Evidence

25
Q

Expert Witness

26
Q

SOAP Reporting

27
Q

SOAPIE(R) Reporting

28
Q

PIE Reporting

29
Q

DAR Reporting

30
Q

SBAR Communication

31
Q

I-SBAR-R Communication

NSG2113 - nursing science (14 decks)

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