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Flashcards in Unit 2 Test Deck (107)
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61

Fairness

Justice

62

Obligation to tell the truth

Veracity

63

Agreement to keep promises

Fidelity

64

Support of a particular cause

Advocacy

65

Willingness to respect one's professional obligations and follow through on promises

Responsibility

66

Ability to answer for one's own actions

Accountability

67

Protect someone's information; keep it private ;example HIPPA

Confidentiality

68

Personally about the worth of a given idea attitude customer object that set standards that influence behavior

Values

69

Begins in childhood ;shaped by experience ;Government ,school ,religion ,social institutions all play a role

Value formation

70

Distinguish among value fact and opinion

Values clarification

71

Ask the question is this an ethical dilemma; gather information relevant to the case; clarify values; verbalize the problem; identify possible courses of action; negotiate a plan; evaluate the plan overtime

Seven steps of processing an ethical dilemma

72

Multidisciplinary; serves several purposes including education policy recommendation and case consultation

Ethics committee

73

Initiate dialogue concerning the client wishes. Do more listening than talking. Assess clients understanding of illness and available treatment options. Allow time to explore values and communicate. Facilitate communicating of clients desires to family and other healthcare providers.

Strategies for providing ethical care

74

The first of the recording of information relevant to data collection planning implementation and client response to care given

Documentation

75

Communication, legal documentation, financial billing, education, research, auditing/monitoring,

Purposes of patient records

76

One way that the healthcare team communicate through Charting. Tracks patient Progress education discharge planning

Communication

77

Best defense is for legal claims associated with nursing care

Legal documentation

78

DRGs are basis for establishing reimbursement For patient care. Document supplies used in treatment done and help support reimbursement

Financial billing

79

Helps anticipate the type of care the patient will need

Education

80

Gather data for the frequency of clinical disorders complications etc.

Research

81

Quality improvement

Auditing/monitoring

82

Be factual, be accurate, be complete, keep current, Be organized

Guidelines for quality documentation and reporting

83

Say what you mean and be descriptive. Do not use words appears or apparently. Quantify measurements accurately. Avoid catch all phrases such as patient comfortable, Record only what you see in here.

Factual Documentation

84

If using paper documentation write neatly and legibly. use proper spelling and grammar. be precise. use military time do not Prepay sentence with patient as the record is only the one patient. Do not use blank space on paper chart. Amend mistakes correctly

Accurate documentation

85

Do not omit significant information

Complete documentation

86

Chart promptly.

Current charting

87

Narrative charting should flow and tell a story. Documentation should follow a logical pattern

Organize documentation

88

Do not document someone else's notes. Do not document care provided by another staff member. Do not criticize other healthcare professionals in the chart. Document noncompliant behavior to defend yourself

Miscellaneous guidelines for charting

89

Narrative charting, problem oriented charting, focus charting, charting by exception, critical pathways

Methods of charting

90

Traditional method. Story like format to document findings. Specific to patient condition/nursing care

Narrative charting