Busy. Please wait.
Log in with Clever

show password
Forgot Password?

Don't have an account?  Sign up 
Sign up using Clever

Username is available taken
show password

Make sure to remember your password. If you forget it there is no way for StudyStack to send you a reset link. You would need to create a new account.
Your email address is only used to allow you to reset your password. See our Privacy Policy and Terms of Service.

Already a StudyStack user? Log In

Reset Password
Enter the associated with your account, and we'll email you a link to reset your password.
Didn't know it?
click below
Knew it?
click below
Don't know
Remaining cards (0)
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

  Normal Size     Small Size show me how


chapter 17

characteristics of effective documentation complete, accurate, concise, factual, organized, confidential
what is confidential for pt? name, address, reason of illness, treatments received, formation about past illness
breaches in pt confidentiality sending emails via pulic networks, discarding copies of pt information in trash cans, holding conversations that can be overheard, faxing confidential info to unauthorized persons
patients' rights see and copy their chart, update their health record, get a list of disclosurese, request a restriction on certain uses or disclosures, choose how to recieve health info
policy for receiving verbal orders record in medical record, read back the order to verify accuaracy, date and and note time orders were issued
duties of RN receiving telephone orders read orders back to practioner to verify, date and note time orders were issued
purposes of pt record communicate with other providers, care planning, research, education, legal documentation, reimbursement
purposes of recording data facilitate pt care, serve as a financial and legal record, help in clinical research
methods of documentation PIE charting, focus charting, electonic medical records
formats/types of nursing documentation inital nursing assessment, kardex, plan of nursing care, progress notes, flow sheets, discharge summary, home healthcare doucmentation, long term documentation
change of shift report consists of___________ id information about pt, current helath status, current orders, summary of pt, report on d/c status
reporting on pt can be done_________________________. face to face, telephone conversations, written messages, audio-taped, computer
ways to confer about pt care consultations, referrals, team care conferences, nursing care rounds
benefits of nursing informatics increase accuracy of documentation, improvment in workflow
computerized nursing care plans must first be individualized to each pt.
patient confidentiality limits conversations about pt care/info only to those caring for pt
Created by: N119
Popular Nursing sets




Use these flashcards to help memorize information. Look at the large card and try to recall what is on the other side. Then click the card to flip it. If you knew the answer, click the green Know box. Otherwise, click the red Don't know box.

When you've placed seven or more cards in the Don't know box, click "retry" to try those cards again.

If you've accidentally put the card in the wrong box, just click on the card to take it out of the box.

You can also use your keyboard to move the cards as follows:

If you are logged in to your account, this website will remember which cards you know and don't know so that they are in the same box the next time you log in.

When you need a break, try one of the other activities listed below the flashcards like Matching, Snowman, or Hungry Bug. Although it may feel like you're playing a game, your brain is still making more connections with the information to help you out.

To see how well you know the information, try the Quiz or Test activity.

Pass complete!
"Know" box contains:
Time elapsed:
restart all cards