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Turner Communication

Communication flash cards

QuestionAnswer
Communication occurs through what 2 methods? Client records, and reporting
What are the purpose of records? Communication Legal Defense Financial Billing Education Research Auditing/Monitoring "If it wasn't charted it never happened"
What is a DRG? Diagnostic Related Groups
Guidelines for charting Information must be factual. Don't use opinions. Info must be accurate, correct and precise, don't use dangerous abbreviations. Charting should be current, timely, and exact. Organized in logical order.
Misc Guidelines C/O = Complaints of Use Military time.
What are methods of reporting? Narrative nurses notes Problem-oriented medical records (POMR) SOAP- Subjective, objective, analysis, planning Focus charting- (OAR) Data, action, responce Charting by exception
If you make a mistake how do you fix it? One single strike through mistake and initials. Write the correct charting and time, date.
What are some benefits of the case management system? It's Multi-disciplinary, care plans show interventions for everyday pt is in hospital for that diagnosis. Better OC for pt. cost effective Document according to pathway.
What are different forms of documentation? admission nursing Hx. Flow sheets & graphic records. Kardex- summary. Activity records Standardized care plan. Discharge summary-
When does discharge begin? On admission.
Other sources of documentation face sheets, Dr. Orders. Doctor progress notes. Hx and physical- lots of info. medication administration records. Laboratory and diagnostic test. Operative records. Advances directives.
What are the advantages of computerized documentation? paperless, and portability.
Disadvantage of computerized documentation Down time. No system= no charting.
Reporting Change of shift, telephone records, verbal orders, transfer pt reports, hand off reports
What is SBAR? Situation, background, assessment, recommendation
Incident reports Do not document about an incident report being filed. No finger pointing in incident report.
Created by: dgreen158