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documentation

Fundies

QuestionAnswer
Cardinal Rule of Documentation? If it was not documented, it was not done.
What are the 6 general times to document? 1Admission 2Transfer 3Discharge,4Ongoing care per policy 5Change in condition 6Communication
What are drawbacks of verbal orders? Increase Risk of error, Not accepted by students. MUST READ ORDER BACK
What is VORB Verbal Order Read Back.
t/F Incident reports are a part of a Pt's chart False. Do not reference incident on chart.
What is I-SBAR-R Introduction Situation Background Assessment Recommendation Read back
What is the most common method of reporting? Face-to-face reporting
Created by: bubbastina