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49 Cards in this Set

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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

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

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

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

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

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

What are the 3 types of consent?

informed consent, implied consent, expressed consent

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

What to do if an incident occurs?

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

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

Who must all incidents be reported to?

Risk management program to look for changes needed to improve safety

Non-verbal communication functions in the following ways:

may repeat/stress spoken word, accent spoken word, regulate spoken word, substitute for spoken word

When should humor not be used?

Life-threatening situations, when there are cultural differences, when there is possibility of legal actions

When is oral reporting used?

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

Advantages and Disadvantages of Oral Reporting

quick method of delivering info, can be easily misunderstood especially when passing through people

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

What can be done to ensure accuracy when oral reporting?

repeat more than once to ensure accuracy

Define the NOD approach

use name when greeting patient, tell them your occupation and explain what you're going to do

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

Give all the legal concerns stated in the textbook

assault, battery, negligence, (vicarious liability), false imprisonment, defamation (libel, slander), invasion of privacy

Libel

written defamation

Slander

spoken defamation

False imprisonment

illegal detention of a person without their consent

Assault

unlawful act that places another person (without their consent) in fear of bodily harm or battery, threat of touching in an injurious way

Battery

touching a person without permission

Negligence

failure to perform duties/activities with due diligence and attention or to meet the standards of regular care

defamation

written or spoken statement that is untrue or harmful to a person's reputation in the community

vicarious liability

hospital/clinic is legally responsible for conduct of employees who are negligent in the course of their duties

Define SBAR

Situation, Background, Assessment, Recommendation

Ethical Principles

autonomy, beneficence, confidentiality, double effect, fidelity, justice, nonmaleficence, paternalism, sanctity of life, veracity, respect for property

autonomy

refers to right of all persons to make rational decisions free from external pressures

beneficence

all acts must be meant to attain good result or to be beneficial

confidentiality

refers to concept of privacy, must not disclose facts of personal information to anyone uninvolved in patient's care

double effect

some actions may produce both a good and bad effect

fidelity

refers to duty to fulfill one's commitments and applies to keeping promises both stated and implied

justice

refers to all persons being treated equally or receiving equal benefits according to need

nonmaleficence

refers to duty to abstain from inflicting harm and duty to prevent harm

paternalism

refers to the attitude that sometimes prompts health care workers to make decisions regarding a person’s care without consulting the person affected

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

veracity

refers to honesty in all aspects of one's professional life

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

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

Radiographic images must have

patient name, identification number, name of facility where taken, right or left marker correctly placed

4 Modes of Thinking

Recall, habit, inquiry, creativity

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

ACMDTT 3 principles

responsibility to the public, profession and to oneself

ACMDTT responsibility to the public

competent care, diversity, dignity, confidentiality, collaboration, informed consent, professional judgement, professional boundaries, record management

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

ACMDTT responsibility to oneself

personal conduct, accountability, personal capacity