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Turner Communication
Communication flash cards
Question | Answer |
---|---|
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. |