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Resp. 4 I

Data management

6 major PURPOSES for correct charting in the medical record Provide info assist in eval status and planning pt care. Provide legal record, provide means of effectiveness of Tx, document care to bill accuratly, document pt response to therapy as evidence, to document compliance with all hospital and federal rules
6 major documentation requirements of TJC as pertains to prescriptions for resp. therapy 1.type of therapy 2. frequency 3. duration of Tx 4. type and dose of medication 5. type of diluent 6. oxygen concentration
TJC The Joint Commission- they set procedures for patient safety
Subjective perceived only by affected individual (things you ccan't see or feel but the patient can) EX. dizziness, pain
Objective perceived by external senses (I, the RT can get readings) EX. HR, BP, RR, breath sounds
incident report legal document- states:date, time, and details of error in delivery of therapy, medication, etc. Must be completed if wrong medication or dose is given
Routes of orders being recieved verbal, computer, telephone
Errors when orders are being received phone-may heard it wrong, receiver may have not written it down Computer-delay in the receipt of the order
Correct procedure for confirming an order Physician must be written on chart, RCP goes to pt chart, opens to physcian order form, the order is noted directly on chart (noted, Tfarrington) new order is then documented in the appropriate location
If order is unfamiliar or confusing what do you do? Do not administer until order is clarified. Notify the supervisor, ask nurse for input, and call the physcian for clarification
Importance of the medical record Legal record that will protect patient, hospital, and care provider
Created by: TnJFarrington12