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Flashcards in ati documentation Deck (12)
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1

documentation

- must be clear, accurate, considering, and accessible
- provide clear understanding and picture of the client
- allows interproffessional team to communicate w each other

2

PIE

problem
intervention
evaluation

3

SOAP

- subjective: symptoms
- objective: clinical impressions the health care provider sees, hears, touches, measures, or smells
- assessment: combines the subjective and objective info to arrive at a nursing home diagnosis
- plan: details steps to treat clients and suggests the need for consultation or additional testing to address clients needs

4

source- oriented

- medical record is a traditional format for documenting within a medical record for all disciplines
- usually devided into specific sections such as history and physical, progress notes, nurses notes, lab reports, diagnostic testing

5

focus charting

centers on specific health care problems and changes in condition, clients events and concerns

Data
Action
Response
(DAR)

6

problem- oriented medical records (stages)

- developing a database (clients history, findings, diagnostics, and lab results
- identifying and numbering specific problems based on clients history. the date the problem is resolved is noted
- plan of action should be formulated for each problem
- there should be ongoing progress notes for each problem

7

all charting should be done using fact acronym

factual
accurate
complete
timely

8

correcting errors in doc

1. keep original doc
2. draw a single line thru entry and write error and initials
3. record the date and time of when the correction was entered
4. do not obscure the original entry with anything such as white out, black permanent marker...
5. document the correct info

9

late charting

1. make sure to identify the entry as a late entry
2. identify which event the late entry is for
3. make sure all new entries are signed and dated
4. identity which event or previous note the new note is referencing
5. make sure there are no blank lines

10

EHR

- systemic digitized doc system to improve client care
- provides comprehensive records
- means of communication
- accounts for every treatment, diagnosis, and provider visit for billing

11

electronic doc guidelines

- never use anyone else's login
- passwords must be strong, unique, changed freq
- log off when doc is complete
- never leave computer without logging off first
- computer monitor should be protected
- electronic sig- ensure name is correct and professional credentials are noted

12

institute of safe medication practices

- devoted to preventing errors that occur within health care
- complies list of abbreviations that are appropriate to use w doc, helping to reduce confusion and errors