Lecture 8 - Documentation and Reporting Flashcards
1
Q
Purpose of Documentation
A
2
Q
Communication and Care Planning
A
3
Q
Legal Documentation
A
4
Q
Funding and Resoure Management
A
5
Q
Auditing and Monitoring (Quality of Care)
A
6
Q
Research
A
7
Q
Education
A
8
Q
Electronic Health Records
A
9
Q
Confidentiality
A
10
Q
Personal Information Protection and Electronic Documents Act (PIPEDA)
A
11
Q
Guidelines for Quality Documentation and Reporting (6)
A
12
Q
Factual Documentation
A
13
Q
Accurate Documentation
A
14
Q
Complete Documentation
A
15
Q
Current Documentation
A
16
Q
Organized Documentation
A
17
Q
Documentation Compliant with Standards
A
18
Q
Types of Documentation
A
19
Q
Narrative Documentation
A
20
Q
Problem-Oriented Health Care Record
A
21
Q
Source Records
A
22
Q
Charting by Exception
A
23
Q
Critical Pathways/ Care Maps
A
24
Q
Documentation as Legal Evidence
A
25
Expert Witness
26
SOAP Reporting
27
SOAPIE(R) Reporting
28
PIE Reporting
29
DAR Reporting
30
SBAR Communication
31
I-SBAR-R Communication
