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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