Wk 7 Legal Scope - Documentation Flashcards
1
Q
Basic information supplied by patients records
A
Patients ID/demographics Admission history Nursing diagnosis or problems Care plans Medical history and diagnosis Orders Progress notes Reports of diagnostic tests Discharge plan and summary Informed consents
2
Q
Purpose of medical record
A
Communication Reimbursement Research Legal documentation Education Auditing/monitoring
3
Q
Documentation guidelines
A
Factual Accurate Complete Current Organized
4
Q
Legal guidelines for documentation
A
Never erase/correction fluid Do not leave blank spaces BLACK INK (no felt-tip/colored ink/erasable ink) Never use pencil Use approved abbreviations Correct spelling Draw line through error (1 line)
5
Q
SOAP
A
Subjective
Objective
Assessment
Plan
6
Q
SOAPIE
A
Subjective Objective Assessment Plan Intervention Evaluation
7
Q
PIE
A
Problem
Intervention
Evaluation
8
Q
DAR (focused charting)
A
Data
Action
Response
9
Q
Explain “charting by exception” (CBE)
A
Concise documentation of routine care, emphasize abnormal finding, identify trends in clinical care
Only write progress note when assessment don’t meet standardized criteria for normal in one or more body systems
10
Q
Identify common record keeping forms
A
Admission nursing history form Flow sheets and graphic records Patient care summary Standardized care plans or clinical care guidelines Discharge summary forms
11
Q
SBAR
A
Situation
Background
Assessment
Recommendation
