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15 Cards in this Set

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WHAT IS THE #1 FUNCTION OF A PATIENT CARE REPORT
ALLOWS THE ER STAFF TO LEARN ABOUT THE MOI, NOI, CARE YOU PROVIDED, STATUS CHANGES OF THE PATIENT, IT BECOMES PART OF A PERSONAL RECORD, HELPS TO ENSURE CONTINUOUS EFFECTIVE CARE
WHAT IS THE #2 FUNCTION OF A PATIENT CARE REPORT
IT BECOMES A LEGAL DOCUMENT, HE WHO WRITES THE REPORT GOES TO COURT, MAY BE CIVIL OR CRIMINAL, MAY BE USED IN LAWSUIT, IF YOU DONT WRITE IT YOU DIDN'T DO IT
WHAT IS THE #3 FUNCTION OF A PATIENT CARE REPORT
ADMINISTRATIVE PURPOSES, BILLING AND INSURANCE INFO,QI, QA
WHAT IS THE #4 FUNCTION OF A PATIENT CARE REPORT
EDUCATION AND RESURCH, REVIEWED FOR RESEARCH, REVEALS PATTERNS AND TRENDS, USED TO TEACH OTHERS HOW TO DOCUMENT UNUSUAL SITUATIONS
WHAT ARE THREE TYPES OF REPORTS
WRITTEN, COMPUTERIZED, ELECTRONIC CLIPBOARDS
WHAT IS ADISADVANTAGE OF ELECTRONIC CLIPBOARDS (PEN BASED COMPUTER)
THERE IS NO PAPER RECORD IF ACCIDENTALLY ERASED OR DESTROIED
PERTINENT NEGATIVES
IMPORTANT NEGATIVE FINDINGS, ASSURE YOU HAVE DONE A COMPLETE ASSESSMENT, THEY VARY ACCORDING TO CHIEF COMPLAINT
WHAT ARE THE ELEMENTS OF GOOD DOCUMENTATION
COMPLETNESS AND ACCURACY, LEGIBILITY, TIMELINESS, CORRECTION OF ERRORS, PROFFESSOINALISM
WHAT DO YOU DO IF MORE INFO NEEDS TO BE ADDED TO A SENT REPORT
SUBMIT AN ADDENDUM WITH THE CORRECTIONS OR ADDITIONAL INFO
ERRORS OF OMISSION
LEAVING OUT IMPORTANT PARTS OF PATIENT CARE, SAYING YOU DID CARE WHEN YOU DID NOT
ERRORS OF COMMISSION
ACTIONS PERFORMED THAT WERE WRONG OR IMPROPER
FALSIFICATION LEADS TO
POOR PATIENT CARE DUE TO HOSPITAL STAFF BEING MISLEAD ABOUT THE PATIENTS CONDITION
SOAP
SUBJECTIVE-WHAT YOU WERE TOLD BY..., OBJECTIVE-WHAT YOU SAW AND FOUND, ASSESSMENT-GENERAL IMPRESSION, PLAN-ACTIONS TAKEN
WHAT SHOULD BE DOCUMENTED DURING A REFUSAL
THAT IT WAS AMA, THAT YOU TALKED TO SUPERVISOR OR DOCTOR, YOU TOLD THE PATIENT TO SEE A DOCTOR OR CALL BACK IF NEEDED, HAVE WITNESS SIGN
CART
CHIEF COMPLAINT, HISTORY, ASSESSMENT, TREATMENT, TRANSPORT