Laws & Ethics
Suicidal Ideation, Childhood Sexual abuse Disclosure, Threatening to hurt others
When can you break confidentiality?
Recorded information regarding the care given, the amount of time taken to provide the care, and the amount of assistance the client needs.
What is used to determine funding for an organization?
spoken account of care provided and observations made.
What is a verbal report?
These are digital version of a patient’s paper chart. They are are real-time, patient-centred records that make information available instantly and securely to authorized users.
EHR Electronic Health Records
assessment, nursing diagnosis, planning, implementation, and evaluation
What is the care-planning process (or nursing process)?
It is important to write with _____ink because someone could alter your noes, it could be hard to read, look amateurish, and be hard to copy.
black ink
A type of writing that conveys facts and information without emotional wording or an emotional tone.
What is objective writing?
a permanent and legal document required to record a client's condition, signs and symptoms of any illness, the care and treatment given to the client, and the client's responses to care.
What is a chart or record?
What does EMR stand for?
Electronic Medical Record
special phrases, short forms, or acronyms used in a given industry.
What is jargon?
Who, What, When, Where, Why
What are the 5 WH's?
allows the writer’s opinions and emotions to be known.
What is subjective writing?
The recordings of what went on every day, for every shift, at a facility, treatment centre, drop-in centre, shelter, or home
What are daily logs?
What is a VPN?
words or phrases that people have invented either to replace other words or to describe a new phenomenon.
What is slang?
obtaining personal information with the formal permission of the client or a person who has the legal authority to provide permission on behalf of the client
What is informed consent?
Writing a report where you record events in the order in which they happened to you.
What does writing chronologically mean?
Recordings from client meetings of what was discussed, your impressions of the client’s emotional or physical state, and any plans you and the client develop.
What are case notes?
An identity and access management security method that requires two forms of identification to access resources and data.
What is 2 factor authentification?
information that is written, verbal, or otherwise expressed information
containing personal or identifying information.
What is confidential information?