Chapter 3: Documentation Flashcard Review

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Fundamentals of Nursing Fichas sobre Chapter 3: Documentation Flashcard Review, creado por SherieChristina el 15/05/2015.
SherieChristina
Fichas por SherieChristina, actualizado hace más de 1 año
SherieChristina
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Resumen del Recurso

Pregunta Respuesta
Chart (health care record) meets the demands of: Health Accreditation Medical Insurance Legal Systems
Adding information to chart is called: *Charting *Recording *Documenting
Documenting should include: *Type of intervention *Time care was rendered *Signature and title of the person providing care is essential
Purposes of Patient Records *Documented communication *Permanent record for accountability *Legal record of care *Teaching *Research and data collection
Patient's chart provides: *Concise, accurate permanent medical record and nursing problems *Plans for care *Care given *The patient's responses to various treatments *Facilitates accurate communication and continuity of care among all members of the health care team
Proper charting covers all areas of patient needs and concerns of: *Physical *Emotional *Psychological *Social *Spiritual
Permanent record is sometimes used by various government and other agencies to: *Evaluate the institution's patient care *Justify cost reimbursement for care provided *Establish or Review Accreditation
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