Save
Busy. Please wait.
Log in with Clever
or
show password
Forgot Password?
Don't have an account?  Sign up 
Sign up using Clever
or
Username is available taken
show password


Make sure to remember your password. If you forget it there is no way for StudyStack to send you a reset link. You would need to create a new account. Your email address is only used to allow you to reset your password. See our Privacy Policy and Terms of Service.

Already a StudyStack user? Log In

Reset Password
Enter the associated with your account, and we'll email you a link to reset your password.
focusNode
Didn't know it?
click below
 
Knew it?
click below
Don't Know
Remaining cards (0)
Know
0:00
edit
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

  Normal Size     Small Size show me how

Chp.5 (HIT-114)Shan.

Pt. Record Documentation Guidelines

QuestionAnswer
Authentication Change in Pt's Condition Entries should be documented and signed(authenticated)by the auther.doucumentation must reflect any changes
Communication with Others Any communication provided to the pt's family or DR. should be properly documented. ex:pt.change of condition on night shift.)Significant information related to the pt's care and treatment should be documented. ex: pt.condition,response to care,tx course,
Consistency Document current observations,outcomes,& progress.>entries should be consistant doc.in record.>in doc. is contradictory, explanation should be included.
Continuous Documentation Providers should not skip lines ro leave blanks when documenting in pt's records.>Do not generate a new form until the previous form is filled.ex:progress note sht.>If new form is started, the provider should cross out any remaining space on the previous
Objective Documentation State facts about pt. care and treatmentINCORRECT:Pt. is pecularCORRECT:Pt. exhibits odd behavior
Referencing Other Patients If other pt's are referenced in the record, do NOT document their names-reference their pt.number(s)only.
Pharmacy Documentaion entries in the patient record are considered permanent and policies and procedures should be established to prevent falsification of and tampering with the record.
Physical Characteristics Select white paper with permanent black printing to ensure readability of paper-base records.>Require providers to enter documentation using permanent black ink.>plain paper(not thermal paper)faxes are best if filed in the pt. record.File original documen
Specificity Document specific information about pt. care and tx.INCORRECT:Eye exam is normalCORRECT:Eye exam reveals pupils equal,round,and reactive to light.
Popular Medical sets

 

 



Voices

Use these flashcards to help memorize information. Look at the large card and try to recall what is on the other side. Then click the card to flip it. If you knew the answer, click the green Know box. Otherwise, click the red Don't know box.

When you've placed seven or more cards in the Don't know box, click "retry" to try those cards again.

If you've accidentally put the card in the wrong box, just click on the card to take it out of the box.

You can also use your keyboard to move the cards as follows:

If you are logged in to your account, this website will remember which cards you know and don't know so that they are in the same box the next time you log in.

When you need a break, try one of the other activities listed below the flashcards like Matching, Snowman, or Hungry Bug. Although it may feel like you're playing a game, your brain is still making more connections with the information to help you out.

To see how well you know the information, try the Quiz or Test activity.

Pass complete!
"Know" box contains:
Time elapsed:
Retries:
restart all cards