Patient documentation

Question 1

Who are are legally and ethically obligated to keep all patient information confidential

Answer 1

nurses

Question 2

Nurses are responsible for protecting what?

Answer 2

medical records from ALL unauthorized readers

Question 3

HIPAA requires that disclosure or requests regarding health information are limited to

Answer 3

the minimum necessary

Question 4

STANDARD: HIPAA & NCQA

Answer 4

current documentations standards require each patient have an assessment
complete within 12-24 horus

Question 5

confidential permanent legal documentation

Answer 5

records/charts

Question 6

oral, written, or audiotaped exchange of info

Answer 6

reports

Question 7

team members communicating in a group

Answer 7

conferences

Question 8

what is essential within the health care team

Answer 8

interdisciplinary communication

Question 9

a professional caregiver giving formal advice to another caregiver

Answer 9

consultations

Question 10

arrangement for services by another provider

Answer 10

referrals

Question 11

PURPOSE OF RECORDS

Answer 11

communication
reimbursement
research
legal documentation
education
auditing/monitoring

Question 12

Legal guidelines for recording

Answer 12

be factual
correct all errors- one line
only chart for yourslef
no blank spaces
time/date

Question 13

Quality documentation:

Answer 13

Factual 
accurate
complete
current
organized

Question 14

Episode-oriented

Key information may be lost from one episode of care to the next.

Answer 14

Paper record

Question 15

A digital version of a patient’s medical record
Integrates all of a patient’s information in one record
Improves continuity of care

Answer 15

electronic health record

Question 16

The traditional method

Answer 16

narrative

Question 17

Database
Problem list
Care plan
Progress notes

Answer 17

Problem oriented medical record

Question 18

SOAPIE

Answer 18

subjective, objective, assessment, planning, intervention, evaluatioln

Question 19

PIE

Answer 19

problem, intervention, evaluation

Question 20

DAR

Answer 20

data, action, response

Question 21

Focuses on documenting deviations

Answer 21

Charting by exception

Question 22

who controls longterm care?

Answer 22

medicare and medicaid

Question 23

Occurs with transfer of patient care
Provides continuity and individualized care
Reports are quick and efficient.

Answer 23

hand off report

Question 24

Situation-background-assessment-recommendation (SBAR)
Document every call
Read back

Answer 24

Telephone reports/orders

Question 25

Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient
Follow agency policy

Answer 25

incident report/ occurence

Question 26

Application of computer and information science for managing health-related data
Focus on the patient and the process of care
Goal is to enhance the quality and efficiency of care provided.

Answer 26

health informatics

Question 27

Advantages of NISs

Answer 27

increase time to spend with patients
better access to info
quality documentation
reduce errors
reduce cost
job satisfied