documentation Flashcards
1
Q
what are key elements of patient care
A
- demographics
- presenting complaint
- vital signs
- initial assessment
- history
- interventions
- handovers
2
Q
what are the 10 rights of medication administration
A
- right drug
- right patient
- right dose
- right route
- right time
- explain to pt
- medication hx
- medical conditions
- drug interactions
- documentation
3
Q
what are 3 key elements needed in accurate documentation
A
- clarity and continuity
- legal validity
- data driven insight
4
Q
what are legal and ethical considerations of documentation
A
- confidentiality
- informed consent
- legislative compliance
5
Q
what is legislative compliance
A
understanding legal requirements for documentation maintaining compliance and minimizes risks
6
Q
how can there be clarity in documentation
A
communicate information concisely and unambiguously avoiding jargon
7
Q
why are real time updates needed in documentation
A
helps to capture accurate information as soon as possible
8
Q
what are challenges to documentation
A
- time constraints
- accuracy pressure
- technology adaptation
