Chapter 4 - Documentation and Communication

<p>Within 24 hours (B)</p> Signup and view all the answers

<p>All of the above (D)</p> Signup and view all the answers

<p>Subjective, Objective, Analysis, Plan (A)</p> Signup and view all the answers

<p>Interventions (A)</p> Signup and view all the answers

<p>When assessment data require additional documentation outside of normal limits. (A)</p> Signup and view all the answers

<p>Staff scheduling (C)</p> Signup and view all the answers

<p>Death, permanent harm, or severe temporary harm. (A)</p> Signup and view all the answers

<p>75% (A)</p> Signup and view all the answers

<p>Medication administration record (MAR) (A)</p> Signup and view all the answers

<p>Protection and privacy of patient information (C)</p> Signup and view all the answers

<p>Electronic Medication Administration Record (A)</p> Signup and view all the answers

<p>They detect assessment data indicating potential problems (B)</p> Signup and view all the answers

<p>Primary provider’s orders (C)</p> Signup and view all the answers

The Patient Medical Record serves as a legal document, a tool for communication and care planning, and a crucial resource for quality assurance, financial reimbursement, and education. It plays a vital role in supporting research activities.

Accurate and timely documentation is crucial for ensuring patient safety. It helps prevent medical errors and facilitates effective communication amongst healthcare professionals.

The electronic medical record (EMR) revolutionizes patient record management. It allows for electronic data entry, automated clinical surveillance, and timely input of assessment data to enhance patient care.

Confidentiality is paramount in patient care. The Health Insurance Portability and Accountability Act (HIPAA) mandates the protection of specific health information.

Communication failures are a root cause of medical errors. 75% of sentinel events, which result in death, permanent harm, or severe temporary harm, are caused by ineffective communication.

SOAP, PIE, and DAR are different methods used to document patient assessment data. Each method utilizes a specific format for recording information, such as subjective information, objective findings, assessment, and plan.

SBAR (Situation, Background, Assessment, Recommendation) is a structured communication template used for concise and clear communication amongst healthcare professionals, particularly in critical situations. It ensures effective and efficient information sharing.

Documentation in the patient record should always adhere to ethical and legal guidelines. Maintaining confidentiality, ensuring accuracy, and using clear and concise language ensures responsible and professional practice.

Ensuring medical records accurately reflect the client's condition and care provided, using appropriate language and avoiding abbreviations unless legally accepted.

The practice of documenting care immediately at the time of interaction with the client, instead of waiting to chart later.

The initial evaluation upon admission of a client to a healthcare facility, encompassing their physical, psychological, functional, social, and spiritual status.

Structured documentation tools used to organize and record essential client information, often including vital signs, medications, and interventions.

A structured format for documenting client care that includes a description of the problem, the interventions implemented, and the evaluation of the effectiveness of those interventions.

A structured format for documenting client care that includes data collected, actions taken, and the response observed.

A type of documentation where only deviations from normal limits or expected assessments require detailed charting.

A key principle in medical documentation, prioritizing clear, complete, and concise writing to ensure accurate and effective communication among healthcare providers.