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17 Cards in this Set
- Front
- Back
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Dynamic and continuous process for sharing information
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Communication
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Major communication techniques used by health care providers
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Reporting and Recording
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What serves as a legal document for recording patient activities?
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The Medical Record
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What act provides health insurance coverage and security following a job loss?
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Health Insurance Portability and Accountability Act
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A legal document, permanent, hospital specific forms, confidential, required signature and licensure
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The Medical Record
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Contains progress notes, nursing dataset, consents, procedure notes, eMAR, and flow sheet
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Legal Record
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True or False, in Informal Record Keeping you must remove all patient identifiers and keep information confidential?
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True
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What are some of the purposes of documentation?
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Communicate the care of plan, identify patterns and changes, improve quality of care, create a legal document that can be used in court
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Effective nursing documentation represents each phase of:
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the nursing process
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Nursing documentation must have evidence of initial and ongoing:
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assessments
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In nursing documentations, it is important to use the patient's ____ _____ to describe
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own words
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When you make an inference on a document, it is important to support it with:
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Evidence
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When documenting, it is important to avoid using what type of language?
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Judgmental
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Which is the correct documentation
a. the patient is tearful and crying b. the patient is afraid |
a. the patient is tearful and crying
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To be precise in describing an occurrence, it is important to note:
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when, where, how, what, outcome
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When you make a mistake when documenting, what is the proper way to conceal it?
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put a line through it, write "error", and initial it
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What 4 things are MANDATORY to document?
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Risk for falls
Knowledge Deficit Restraints Discharge Planning |
