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Standing Order Physician orders preapproved by the medical staff that direct the continual administration of specific activites for a specific period of time as a part of diagnosis or therapeutic care
Routine Order Physician orders preapproved by the medical staff, which are preprinted & placed on a patients record
Discharge Order The final physician order documented to release a patient form a facility
Permanency Documentation entries in the patient record are considered permanent & policies & procedures should be established to prevent falsifiation of & tampering with the record
Do Not Resucitate(DNR) Order Tells the medical professionals not to perform cardiopulmoary resuscitation(CPR)
Continuous Documentation Providers should not skip lines or leave blanks when documenting in the patient record. Do not generate a new form.If a new form is started,the provider should cross out any remaining space on the previous form.
Objective Documentation State facts patient care & treatment, & avoid documentating opinons. INCORRECT: Patinet is peculiar. CORRECT:Patient exbhits odd behavior
Created by: Courtneey