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HIT CH.5 CONT.
CH.5 CONT
Question | Answer |
---|---|
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 |