Unit two documentation Flashcards
What is the relationship between informatics and quality health care?
Informatics plays a critical role in enhancing the quality of health care by improving data management and communication.
Identify key reasons for reporting and recording client care.
Key reasons include:
* Ensuring continuity of care
* Legal documentation
* Quality assurance
* Communication among health care providers
Describe guidelines for effective documentation and reporting in health care settings.
Guidelines include:
* Clarity and accuracy
* Timeliness
* Confidentiality
* Completeness
Compare different methods used in documentation.
Methods include:
* Electronic health records (EHR)
* Paper records
* Voice recognition software
Identify common record-keeping forms.
Common forms include:
* Admission forms
* Progress notes
* Discharge summaries
Describe the process of giving and receiving hand-off of care.
The process involves:
* Clear communication of patient information
* Verification of understanding
* Opportunity for questions
What is the purpose of the Health Record?
The purpose includes:
* Providing a comprehensive view of patient history
* Supporting clinical decision-making
* Facilitating research and education
True or False: Documentation systems are essential for accountability in health care.
True
What are the contents of the Health Record?
Contents include:
* Patient demographics
* Medical history
* Treatment plans
* Progress notes
Fill in the blank: Effective documentation must be _______.
[clear and accurate]
