Types of Information
Physician's orders document ___. Give two examples.
What are any orders for patient care?; What are medications, treatments, tests, and follow-up care?
A ___ is assigned to each service that a patient receives.
What is a code?
You should never give you what to ANYONE?
What is a personal password or computer signature?
This is documented in the progress notes section
What is any contact made between any health care professional and the patient?
The first rule of accuracy
What is make sure the information is recorded in the correct patient's record?
Four things that would be included under social history
What is marital status, occupation, education, hobbies, diet, alcohol or tobacco use, and sexual history?
Patient records are ____ and admissible as evidence in court proceedings.
What are legal documents?
You should never use an email to send protected health information unless what?
What is it has been encrypted?
Narrative notes the worse of the three types of progress notes for these reasons
What is that are the oldest and least structured, time-consuming, and can be difficult to read?
This is not necessary to include in the entries of a medical record
What is the patient's name? (Each medical record only belongs to one person)
A grid-like form used to record and monitor specific patient variable over time is ____.
What is a graphic (flow) sheet?
The two key purposes of medical documentation
What is communicating with other health care professionals and describing a patient's current medical condition and history?
Words such as “good,” “average,” “normal,” or “sufficient" should be avoided why?
What is they may be interpreted differently depending on the reader?
Military time is used in health care facilities to _____.
What is avoid confusions between a.m. and p.m. times?
Illegible handwriting increases this (name 2)
What is difficulty reading, misunderstandings/miscommunications, and the possibility of mistakes and miscalculations
End-of-life decisions, organ donation forms, a living will, and a durable power of attorney for health care all fall under this category.
What is correspondence and miscellaneous documentation?
Assessment data provides this opportunity
What is compare data from one visit to another to determine the right diagnosis and treatment plan?
You should never document a medical intervention when?
What is before carrying it out?
The four parts that make up a SOAP note and the difference between the first two
What is subjective, objective, assessment, and plan? What is subjective is statements from the patient and objective is information from the health care professionals observations?
The four sections of a problem-oriented medical record are these
What is problem list, database, treatment plan, and progress notes?
Gathering a social history is important because of these reasons.
What is it helps providers understand how the patient's lifestyle may affect and illness and how the illness and treatment may affect the patient's lifestyle?
How do medical records contribute to research?
What is they help researchers learn how to recognize or treat problems by examining similar cases?
The steps you follow when you make an error on a written chart
What is draw a single line through the incorrect entry and write the words “mistaken entry” or “error in charting” above or beside the entry (include correct information, date, and initials)?
Five benefits of charting by exception
What is decreased charting time, increased time for direct patient care, greater emphasis on significant data, easy retrieval of significant data, timely beside charting, standardized assessment, greater interdisciplinary communication, better tracking of important patient responses, and lower costs?
What is the farther back you go in each section, the older the information is (most recent information appears first)?