chapter 17
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| characteristics of effective documentation | complete, accurate, concise, factual, organized, confidential
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| what is confidential for pt? | name, address, reason of illness, treatments received, formation about past illness
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| 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
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| 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
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| policy for receiving verbal orders | record in medical record, read back the order to verify accuaracy, date and and note time orders were issued
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| duties of RN receiving telephone orders | read orders back to practioner to verify, date and note time orders were issued
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| purposes of pt record | communicate with other providers, care planning, research, education, legal documentation, reimbursement
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| purposes of recording data | facilitate pt care, serve as a financial and legal record, help in clinical research
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| methods of documentation | PIE charting, focus charting, electonic medical records
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| 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
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| change of shift report consists of___________ | id information about pt, current helath status, current orders, summary of pt, report on d/c status
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| reporting on pt can be done_________________________. | face to face, telephone conversations, written messages, audio-taped, computer
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| ways to confer about pt care | consultations, referrals, team care conferences, nursing care rounds
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| benefits of nursing informatics | increase accuracy of documentation, improvment in workflow
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| computerized nursing care plans | must first be individualized to each pt.
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| patient confidentiality limits | conversations about pt care/info only to those caring for pt
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Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
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To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
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