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49 Cards in this Set
- Front
- Back
What is the purpose of charting? |
provide a medical, legal, and multidisciplinary function; record relevant patient care info; for the treatment and care of a patient; for the teaching of a patient |
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Why is charting useful? |
future admissions to hospital; teaching purposes; guide to doctors for improving diagnosis and treatment; guide to all health personnel; research tool |
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What should a technologist chart? |
documenting all MR procedures performed; patient's condition upon arrival in MR; regular monitoring during patient's stay in MRI; patient's condition upon discharge from MRI; medications administered; adverse reactions to medications; names and credentials of people performing procedures; any other info received from patient |
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What to do if an error is written on record |
draw line through mistaken entry, write "mistaken entry" above it, initial/sign above error, then write correct entry |
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Why are requisitions important? |
a doctor will write up a requisition looking for something; have to have doctor monitoring how much diagnostic imaging someone receives; every MR scan will involve a requisition and legally cannot be done without one; legal document |
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What must a requisition include? |
patient name, age, gender, LMP (last menstrual period), identification number, patient's doctor, clinical history pertaining to procedure, name of facility where images are taken, MRI contraindications, surgical history, examination requested with history |
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What are the 3 types of consent? |
informed consent, implied consent, expressed consent |
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Why are incident reports filled out? |
accident/injury to patient/staff/visitor, loss of/damage to property/patient/staff/visitor/hospital, incorrect drug or procedure administration, incorrect events that occur during a procedure |
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What to do if an incident occurs?
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care for patient, notify physician or healthcare worker, complete incident form, use patient quotes of pertinent, evaluate situation, forward forms, follow WCB if staff member is injured |
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What should be recorded on an incident report? |
what occurred, how it occured, time, date, room, department, to whom, who was present, what was done to alleviate situation at the time, condition of individual involved, signature of all witnesses or participants involved
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Who must all incidents be reported to? |
Risk management program to look for changes needed to improve safety |
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Non-verbal communication functions in the following ways: |
may repeat/stress spoken word, accent spoken word, regulate spoken word, substitute for spoken word |
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When should humor not be used? |
Life-threatening situations, when there are cultural differences, when there is possibility of legal actions |
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When is oral reporting used?
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in emergency situations when results are needed quickly, to discuss pertinent and specific patient care questions, to coordinate with other health care providers and to clarify patient treatment and care |
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Advantages and Disadvantages of Oral Reporting |
quick method of delivering info, can be easily misunderstood especially when passing through people |
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What must be done when oral reporting on the phone? |
Verify who you are talking to; ask person to read back what you said to ensure they have correct info; even write down who you talked to, date/time, what was discussed |
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What can be done to ensure accuracy when oral reporting? |
repeat more than once to ensure accuracy |
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Define the NOD approach |
use name when greeting patient, tell them your occupation and explain what you're going to do |
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Ways to be an active listener: |
make eye contact, take listening position, paraphrase speaker's message, ask clarifying questions, make comments, answer questions, provide feedback, empathy, openness, awareness |
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Give all the legal concerns stated in the textbook |
assault, battery, negligence, (vicarious liability), false imprisonment, defamation (libel, slander), invasion of privacy |
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Libel |
written defamation |
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Slander |
spoken defamation |
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False imprisonment |
illegal detention of a person without their consent |
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Assault |
unlawful act that places another person (without their consent) in fear of bodily harm or battery, threat of touching in an injurious way |
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Battery |
touching a person without permission |
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Negligence |
failure to perform duties/activities with due diligence and attention or to meet the standards of regular care |
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defamation |
written or spoken statement that is untrue or harmful to a person's reputation in the community |
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vicarious liability |
hospital/clinic is legally responsible for conduct of employees who are negligent in the course of their duties |
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Define SBAR |
Situation, Background, Assessment, Recommendation |
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Ethical Principles |
autonomy, beneficence, confidentiality, double effect, fidelity, justice, nonmaleficence, paternalism, sanctity of life, veracity, respect for property |
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autonomy |
refers to right of all persons to make rational decisions free from external pressures |
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beneficence |
all acts must be meant to attain good result or to be beneficial
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confidentiality |
refers to concept of privacy, must not disclose facts of personal information to anyone uninvolved in patient's care |
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double effect |
some actions may produce both a good and bad effect |
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fidelity |
refers to duty to fulfill one's commitments and applies to keeping promises both stated and implied |
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justice |
refers to all persons being treated equally or receiving equal benefits according to need |
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nonmaleficence |
refers to duty to abstain from inflicting harm and duty to prevent harm |
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paternalism |
refers to the attitude that sometimes prompts health care workers to make decisions regarding a person’s care without consulting the person affected |
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sanctity of life |
refers to the belief that life is the highest good and nobody has the right to judge that another person’s quality of life is so poor that his life is not of value and should be terminated |
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veracity |
refers to honesty in all aspects of one's professional life |
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respect for property |
refers to keeping the patient’s belongings safe and taking care not to intentionally damage or waste equipment or supplies with which one works |
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Why are medical records kept? |
to transmit information about patient between health care workers, protect patient from medical errors and duplication of treatments, provide info for medical research, protect health care worker in cases of litigation, provide info concerning quality of patient care for institutional evaluation teams |
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Radiographic images must have |
patient name, identification number, name of facility where taken, right or left marker correctly placed |
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4 Modes of Thinking |
Recall, habit, inquiry, creativity |
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therapeutic communication techniques |
establishing guidelines, reducing distance, listening, using silence, responding to the underlying message, restating the main idea, reflecting the main idea, seeking and providing clarification, making observations, exploring, validating, focusing |
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ACMDTT 3 principles |
responsibility to the public, profession and to oneself |
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ACMDTT responsibility to the public |
competent care, diversity, dignity, confidentiality, collaboration, informed consent, professional judgement, professional boundaries, record management |
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ACMDTT responsibility to the profession |
personal responsibility, honesty, boundaries of competence, duty to report, conflict of interest, advancing the profession, integrity and respect, legislative requirements, professional comunication |
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ACMDTT responsibility to oneself |
personal conduct, accountability, personal capacity |