2735334
Description
Flashcards by SherieChristina, updated more than 1 year ago
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Created by SherieChristina
over 9 years ago
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| Question | Answer |
| Basic Rules for Documentations | All documents should have the correct patient name, identification number, date of birth, date, and time if appropriate. |
| Basic Rules for Documentation | Use only approved abbreviations and medical terms. |
| Basic Rules for Documentation | Be timely, specific, accurate, and complete |
| Basic Rules for Documentation | Write legibly (for written documentation) |
| Basic Rules for Documentation | Follow rules of grammar and punctuation. |
| Basic Rules for Documentation | Fill all spaces; leave no empty lines. Chart consecutively. Go line by line. Do not indent left margin. |
| Basic Rules for Documentation | Chart after care is provided, not before. |
| Basic Rules for Documentation | Chart as soon and as often as necessary. |
| Basic Rules for Documentation | Chart only your own care, observations, and teaching; never chart for anyone else. |
| Basic Rules for Documentation | Use direct quotes when appropriate. |
| Basic Rules for Documentation | Be objective in charting; only what you hear, see, feel, smell. |
| Basic Rules for Documentation | Describe each item as you see it: for example, "white metal ring with clear stone" (rather than "diamond ring"). Do not speculate, guess, or assume. |
| Basic Rules for Documentation | Chart facts; avoid judgmental terms and placing blame. |
| Basic Rules for Documentation | Document only what you observe, not opinions. Never use charting to accuse someone else. |
| Basic Rules for Documentation | Document only what you observe, not opinions. Never use charting to accuse someone else. |
| Basic Rules for Documentation | Sign each block of charting or entry as directed by the agency policy. |
| Basic Rules for Documentation | Sign each block of charting or entry as directed by the agency policy. |
| Basic Rules for Documentation | When a patient leaves a unit (e.g., to go to x-ray laboratory, or office), chart the time and the method of transportation of departure and return. |
| Basic Rules for Documentation | Chart all ordered care as given or explain the deviation (nothing by mouth [NPO] for laboratory, off unit, refused, etc). |
| Basic Rules for Documentation | Note patient response to treatments and response to analgesics or other special medications. |
| Basic Rules for Documentation | Use only hard-pointed, permanent black ink pens; no erasures or correcting fluids are allowed on charts for written patient records. |
| Basic Rules for Documentation | If a charting error is made, identify the error according to facility policy and make the correct entry. |
| Basic Rules for Documentation | When making a late entry, note it as a late entry and then proceed with your notation: for example, "Late entry ____________," or as dictated by the facility policy. |
| Basic Rules for Documentation | Follow each institution's policies and procedures for charting. |
| Basic Rules for Documentation | Avoid use of generalized empty phrases such as "status unchanged" or "had good day." |
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