Written Communication Final Flashcards
*Explain the importance of written
communication 5
- Continuity of care
- Legal protection
- Reimbursement
- Quality improvement
o Identify a problem
o Educating staff
o Re-evaluation for resolution - Regulatory standards -(can be fined or lose
certification of a facility)
Demonstrate the 13 essential guidelines for
charting in a medical/dental record
- Time
- Abbreviations
- Punctuation
- Active Voice
- Spelling
- Concise
- Specific
- Write Legibly
- Organization
- Stick to the Facts
- Sign and Date all Entries 12.Making Corrections 13.Making Late Entries
If Used incorrectly, can lead to confusion,
errors, wrong dosages and incorrect tx
Abbreviations and Symbols
Active Voice conveys a ___ and ___ portrayal of events. Start your sentence with a ___
natural
direct
verb
Spelling incoorectly is unprofessional, lazy and poor judgment. Biggest concern is spelling ___ wrong
medications
Is it better to be concise with chart notes or write a narrative
Concise
Words that are vague can be misinterpreted
(disoriented or confused)
so be ___
Specific
The purpose of a medical record
is to communicate information
between ______ ___ ____
health care providers
Organize your chart note information in ____ order
chronological order
Stick to the facts do not put your personal ____ or __ into charting… just state facts.
assumptions
bias
You must ___ and date all entries
sign
Making Corrections: Draw a single line through the error; the error should be legible and write “____entry”
mistaken
What to do when making a late entry
Write “late entry” with a brief note stating why this information was not charted. Make the appropriate information and sign the entry
What are the 5 NEVERS of documenting
- Document for someone else
- Ask someone else to document for you
- Document false information
- Delete, erase, scribble over or white out
- Tamper with the medical record
What are the 2 Charting Systems
PIE
SOAP
PIE NOTES
-Problem (explanation of
the problem)
-Implementation (or
action taken)
-Evaluation (how the patient feels now and level of comprehension of teaching)
SOAP Notes
-Subjective (what the patient says) -Objective (what you observed) -Assessment -Plan (what you plan to do to correct the problem)
PACIFIC UNIVERSITY CHART NOTE
CHART
Concern (patient concerns) History (pertinent medical & dental hx alerts)
Assessments Recommendations Treatment provided
NV: plan for the next appointment
PARQ
Signature
C in Chart note means
Concerns
A summary statement which includes the patient’s concern(s) and concerns from a referral source. • Why has the patient come today? • Patient was referred for dental cleaning by
physician
H in Chart note means
Health and Dental History
• Start with ASA? State any systemic problems
that may require additional treatment
modifications (recent heart attack,
diabetes…) • State vital signs, elevated blood sugar levels,
AIC, clotting time, etc. • Include: Last dental visit or irregular dental
care
A in CHART
Assessments
Include all assessments findings completed today. May include: • AAP • Oral hygiene status • PI/GI • Radiographic findings • Caries • Lesions • Risk Assessment • Gingival Descriptions
R- CHART
Recommendations
• All recommendations given during this appointment. • Recommended treatment • Oral hygiene instructions– include tool and technique) • Referrals (to who, for what), • Premedication • Recare interval (# of months and time needed) • Other?
T in Chart
Treatment
T in Chart
Treatment
• All recommendations given during this
appointment. • Recommended treatment • Oral hygiene instructions– include tool and
technique) • Referrals (to who, for what), • Premedication • Recare interval (# of months and time
needed) • Other?
Chart note NEXT Visit should always include
OHI
*** What does PARQ mean in CHART
P= Procedure A= Alternatives R= Risks and Benefits Q= Questions
Consent form to be signed must include
– Problem – Type of procedure – Statement of risks and benefits – Expected outcomes – Agreement by the patient – Cost (in our clinic)
Telephone Communication document the following: Document the following
– Problem – Type of procedure – Statement of risks and benefits – Expected outcomes – Agreement by the patient – Cost (in our clinic)
Guidelines for Referrals: Communicate the following informations
• Type of services needed
• Prior services rendered
• Date services should begin • Goals of the service
• Specific instructions
• Include necessary radiographs, charts and
information
C O N S U L T
Clarify terms you do not understand prior to
making the call
Objective data (pt name, age, contacts)
Necessary Past Hx
Symptoms/signs
Unusual Circumstances
Looking: what services the patient is looking to
obtain
Time: when you need services to start
