EMR
Documentation
Plan of Care / Communication
Malpractice/Negligence
Terms
100
This is a way that improves a providers access to patient data
What is EMR (The Electronic Medical Record)
100
Charting must reflect
What is the patient story - well written, thorough assessment, care provided and reaction to that care Years later you may have to recall this information in a court of law!
100
If you obtain a high reading such as blood pressure or pulse, take this step first
What is wait 5 minutes, retake the vital signs then report if out of range, document, and provide patient education
100
List a malpractice issue that may affect nurses at CCOC
What is Medication error, Failure to follow a doctors order, Failure to monitor a patient, Failure to notify a physician of change in patient condition, Failure to follow policy and procedure
100
Topic in which law prohibits the release of medical information unless the patient consents, other providers need to know, it is required by law, or needed for billing.
What is Confidentiality
200
Printable forms that help the provider explain information to patients.
What is Education Materials
200
Patient states: "I fell and my right foot went underneath me, have had pain and swelling in right ankle for 5 days" This is an example of ?
What is Chief Complaint
200
This drives the patient care that is provided, moves the patient toward return to home
What is the Plan of Care / Care Plan
200
Where do incident reports go?
What is to the Quality/Risk Management Department NOT a permanent part of the Medical Record
200
The duty to help others by doing what is best for them without inflicting evil or harm
What is Beneficence / Nonmaleficence
300
Number one way to reduce errors with any medical record or patient care.
What is Use of 2 patient identifiers: Name and Birthdate
300
Error correction should be completed by this person
What is the employee who documented incorrectly, no one has the right to correct other's documentation
300
Tool used to provide standardized communication across the health care setting
What is SBARQ
300
Failure of an individual to not perform an act
What is Negligence
300
A law that addresses wrongful acts, whether unintentional or intentional, against a person or property
What is Tort Law
400
Missed a medication or treatment at 2 pm - this is called ?
What is Documentation of Omission in Care Change in response should be documented Incident report sent to Quality
400
The most important point in legal documentation is?
What is Timely Documentation
400
Consent must include
What is side of surgery, actual surgery, patient signature, witness sigature
400
Four elements that must be present for malpractice to exist?
What is Duty, Breach of duty, causation, and injury
400
The legal principle that allows the court to hold an employer responsible for the actions of an employee when performing services for the organization
What is Respondeat Superior
500
The goal of ____ is to improve health care in the United States.
What is Meaningful Use Complete and accurate information Better access Patient empowerment
500
When you document an intervention - you must document an ?
What is an Evaluation
500
When a patient refuses treatment- this assessment should be documented?
What is Mental Status
500
Negligence and Malpractice fall under this type of law
What is Tort Law (Unintentional Tort)
500
Federal law requiring every health care facility receiving Medicare or Medicaid to provide written information to adult patients concerning their right to make health care decisions
What is Patient Self Determination Act
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