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17 Cards in this Set
- Front
- Back
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written evidence of interventions that occur between patient, family and healthcare providers
aka - charting |
Documentation
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all information about a patient written on paper, spoken aloud, saved on computer are considered confidential under ...
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HIPA
Health insurance Portability and Acountability Act |
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patients rights :
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see and copy health records.
update health record. get a list of disclosures request a restriction on certain use or disclosures. choose how to recieve health info |
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what are the purposes of charting/documentation
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planning care
communication legal documentation research education quality assurance statistics accrediting and liscencing reimbersement |
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a type of record that is traditional chart, sectioned out, must write progress notes
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source oriented clinical record
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a chart with patient problems
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problem oriented clinical record
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a format for RN documentation - initiated upon admittance by an RN , revised with patient change of condition
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nursing care plan
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a format for RN documentaion - standard plans of care - combo of RN and medical - set pattern
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critical pathways
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a format for RN documentation - this is a patient care summary - patient full order of both medical and RN
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kardex
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these are what you document on, if you cant you must write a progress note
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flow sheet
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a progress note organized by subjective/objective/assessment/plan is called
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SOAP
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a progress note that is a short story to document specific findings
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narrative charting
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a progress note organized by problem, intervention and evaluation
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PIE
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if PT condition not at normal limits, if it can;t be described or out of the ordinary, you can ....
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Chart by exception
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a progress note focused on data/action and response is called
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Focus charting, DAR
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Name the guidelines for Recording
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timing
confidentiality permancence signature accuracy sequence appropriateness standard terminology brevity legal awareness |
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support all observations with ___________ data
ex) measured data |
objective
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