Definitions
anything written or printed that is used in a patient's medical record
What is documentation?
HIPPA
What is health insurance portability and accountability act?
Three types of charting
What is narrative, problem- oriented and charting by exception?
PCC pen color
what is black?
baby don't hurt me
What is love?
long term electronic charting
What is EHR?
PHI
What is protected health information?
body system by body system
What is narrative charting?
PCC sign off
What is S. Student SN/PCC?
edible liquid evil
What is prune juice?
short term or single visit electronic charting
What is EMR?
protocol for a patient accessing their chart
What is a release form?
charting that involves SOAP PIE DAR
What is problem oriented charting
avoided at all costs when paper charting
What is white out or erasure?
to whales as rice is to us
What is krill?
defining characteristics of quality charting
What is factual, accurate, SN/PCC, complete, current, sequential, organized?
violation of student nurse's role within HIPPA
What is discussing details with other students?
charting that involves WDP
1 min safety assessment
What is
pt. safe with ABC's
Id band on? allergy bracelet on?
fall risk
isolation precautions
quiet village
What is every day like the one before?
avoided during quality charting
What are generalizations?
what are bias and labels?
What are unapproved abbreviations?
Name 10 HIPPA identifiers
What are any number of unique identifiers?
elaborate on SOAP, PIE, and DAR
What is problem, interventions, and evaluation?
What is data action response?
three types of isolation precautions and the diseases memorized for each
What is contact, droplet, and protective? etc
last thing Emily washed
where is the shower curtain?