DOCUMENTATION Flashcards
(14 cards)
FACT for charting
Factual, Accurate, Complete, Timely
True or False? verbal prescriptions should be reserved for emergency situations.
true
Can you accept verbal prescriptions for chemotherapeutic medications?
Yes, but only if the directive is to stop or withhold the medication.
CPOE systems allow providers to
write and transmit prescriptions electronically
When a particular medication is prescribed, the CDSS will
recommend doses, routes, frequencies of administration, and other safety features such as allergy checks, interactions, and laboratory warnings.
(CDSS) feature
clinical decision support system
PIE model
problem, intervention, evaluation
why do a lot of institutions no longer use a source-oriented medical record?
it involves separate documentation by each professional, leading to fragmented care.
Four components of POMR (problem-oriented medical record)
a database in which assessment data are documented, a problem list in chronological order, an initial plan, progress notes using SOAP format
SOAP format stands for
subjective,objective,assessment, plan
What is Focus charting?
documents a client’s specific health care problem by focusing on the nursing diagnosis as well as changes in the client’s condition, events, and concerns
The three items that must be documented when using the focused charting method are
data, action, and response (DAR)
The charting by exception (CBE) method focuses on documenting only
unexpected or unusual findings based on standardized protocols.
