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HIT CH. 5
CH.5
| Question | Answer |
|---|---|
| Living Will | Legal document in which patients states the kind of health care they do or do not want under certain circumstances |
| Special Consent | Include.. Name of the patient, Type and limitations of procedure, Risks of procedure,Alternatives to proedure,Signature of person qualified to give consent and date,Name of surgeon perfoming procedure,Physician/Surgeon signature,Witness signature and date |
| Health Care Proxy(or durable power of attorney) | Legal document in which patients name someone close to them to make decisions about health care in the event they become incapacitated |
| Specificity | Be sure to document specific information about patient care and treatment. Avoid vague entries.INCORRECT: eye exam is normal.CORRECT:Eye exam reveals pupils equal,round & reactive to light |
| Physical Characteristics | Select white paper with permanent black printing to ensure readbility pf paper-based records. Require providers to enter documentation using permanent black ink |
| Referencing Other Patients | If other patient(s) are reffered in the reocrd, do not document their name(S) instead |
| Consistency | Document current observations,outcomes, and progress. Entries should be consient with documentation in the record, if documemtation is contradictory, an explantion should be included |
| Completeness | Signifiacnt information related to the patient's care & treatment should be documented.All fields on preprinted forms should be completed.If an original entry is incomplete the provider should amend the entry. |
| Communication with Others | Any communication provided to the patinet's family or physician should be properly documented |
| Authication Change in Patient's Condition | Entires should be documented and signed by the author.If the patient's conditionchanges or a siginicant patientcare issue develops documentation must reflect his well as indicate follow-through |
| Birth Certificate Includes,.... | Infants and parents demographic information,Parent's occuptaion,education,ethnicity,race.Pregancy inoformation,Medical reisk factors,complications,&/or abdnormal conditions of newborn |
| Certificate of Death include... | Name of deceased,deceased's date & place of death,usual residence of desceased at time of death,cause of death,deceased'd place of birth,names & birth places of both parents,name of docotr,name of informat,signature of funeral director, |
| History and Physical Examination | perpared as one handwritten or transcribed report |
| Chief Compliant(CC) | Patients descrpition of medical condition, stated in the patients own words |
| History of Present Illness (HPI) | Chronological descripition of patients present condition from time of onset to present HPI shouild include location,quailty,servity,duration of the condition, &associated signs & sypmtions |
| Medications | A listing of currnt medications and dosages |
| Review of Systems (ROS) | Inventory by systems to document subjective symptons stated by the patient |
| ROS Includes | general, skin, breats, respiratory, thorat, mouth, nose, ears, eyes, head, allergic/immunologic, endorcrine,hematologic/lympjatic,psychological,neurological,muscularskeletal,genitourinary,gastrointestinal,cardiovascular |
| As part of the consulation process, the consulting physicain.... | reviews the patinets record,provides recommendations &/or opinions,documents pertient findings,examines the patient |
| Anti-Dumping Legislation(Emergency Medical Treatment and Labor Act, EMTALA) | Prevents facilities licensed to provide emergency services from transferring patients who are unable to pay to other institutions, & it requires that a patients condition must be stablizied prior to transfer(unless the patient requests transfer) |
| Contents of a discharge summary include: | Patient & facility identification, Admission & discharge dates, Reason for hospliatalization(brief clinical statment of chief complaint & history of present,HPI) |
| History and Physical Examination | Is prepared as one handwritten or transrcibed report, whcih assists the physician in establishing a diagnosis on which to base treatment & serves as a reference for future illnesses |
| Written Order | Orders that are handwritten in a paper-based record or entered into an electronic health record by the responsbile physician |
| Voice Order(V.O.) | A verbal order dictated to an authorized facility staff member by the responsbile physician who also happens to be present |
| Verbal Order | Orders dictated to an autorized facility staff member |
| Transfer Order | A physician order documented to transfer a patient from one facility to another |
| Telephone Order (T.O.) | A verbal order dictated via telephone to an authorized facility staff member. |
| Stop Order (or Authomatic Stop Order) | As a patient safety mechanism,state law mandates & in the absence of state law facilities decide, for which circumstances preapproved standing physician orders are automicatically discounted(stopped), requring the physician to document a new order |
Created by:
Courtneey
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