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Lesson 28 unit 5 test
Documentation
17
Nursing
Professional
11/02/2012

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Cards

Term
legal guidelines for recording 1-10
Definition
do not erase, no personal opinions, correct promptly, factual recording, black ink, no blank spaces, note clarified orders, chart for self only,no generalized phrases, military time, protect password
Term
quality recording is
Definition
factual, accurate, complete, current, organized, confidential
Term
SOAP
Definition
subjective- objective- assessment- plan
Term
PIE
Definition
problem- intervention- evaluation
Term
DAR
Definition
data- action- response
Term
charting by exception
Definition
focuses on deviations from the norm
Term
Kardex
Definition
NOT a legal document- can use a pencil and erase
Term
the critical pathways
Definition
multidisciplinary team
Term
to fix error in recording
Definition
draw a single line thru error, write "error" above it and sign, date, time
Term
to record patient comments
Definition
quote
Term
referral
Definition
arrangement of services
Term
consultation
Definition
formal advice
Term
common reports given by nurses
Definition
change-of-shift reports, telephone reports, hand-off reports, incident reports
Term
nurses must meet the minimum standard of care
Definition
for every task they perform
Term
who has legitimate access to pt records?
Definition
only staff directly involved w that pt.
Term
staff may not discuss what w other staff?
Definition
examination, observation, conversation, diagnosis, or treatment of their pts.
Term
current documentation standards require that all pt have what kind of assessments?
Definition
physical, psychosocial, environmental, self-care,knowledge level, and discharge planning.
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