HFD DOCUMENTATION
Terms
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- WHAT IS THE #1 FUNCTION OF A PATIENT CARE REPORT
- ALLOWS THE ER STAFF TO LEARN ABOUT THE MOI, NOI, CARE YOU PROVIDED, STATUS CHANGES OF THE PATIENT, IT BECOMES PART OF A PERSONAL RECORD, HELPS TO ENSURE CONTINUOUS EFFECTIVE CARE
- WHAT IS THE #2 FUNCTION OF A PATIENT CARE REPORT
- IT BECOMES A LEGAL DOCUMENT, HE WHO WRITES THE REPORT GOES TO COURT, MAY BE CIVIL OR CRIMINAL, MAY BE USED IN LAWSUIT, IF YOU DONT WRITE IT YOU DIDN'T DO IT
- WHAT IS THE #3 FUNCTION OF A PATIENT CARE REPORT
- ADMINISTRATIVE PURPOSES, BILLING AND INSURANCE INFO,QI, QA
- WHAT IS THE #4 FUNCTION OF A PATIENT CARE REPORT
- EDUCATION AND RESURCH, REVIEWED FOR RESEARCH, REVEALS PATTERNS AND TRENDS, USED TO TEACH OTHERS HOW TO DOCUMENT UNUSUAL SITUATIONS
- WHAT ARE THREE TYPES OF REPORTS
- WRITTEN, COMPUTERIZED, ELECTRONIC CLIPBOARDS
- WHAT IS ADISADVANTAGE OF ELECTRONIC CLIPBOARDS (PEN BASED COMPUTER)
- THERE IS NO PAPER RECORD IF ACCIDENTALLY ERASED OR DESTROIED
- PERTINENT NEGATIVES
- IMPORTANT NEGATIVE FINDINGS, ASSURE YOU HAVE DONE A COMPLETE ASSESSMENT, THEY VARY ACCORDING TO CHIEF COMPLAINT
- WHAT ARE THE ELEMENTS OF GOOD DOCUMENTATION
- COMPLETNESS AND ACCURACY, LEGIBILITY, TIMELINESS, CORRECTION OF ERRORS, PROFFESSOINALISM
- WHAT DO YOU DO IF MORE INFO NEEDS TO BE ADDED TO A SENT REPORT
- SUBMIT AN ADDENDUM WITH THE CORRECTIONS OR ADDITIONAL INFO
- ERRORS OF OMISSION
- LEAVING OUT IMPORTANT PARTS OF PATIENT CARE, SAYING YOU DID CARE WHEN YOU DID NOT
- ERRORS OF COMMISSION
- ACTIONS PERFORMED THAT WERE WRONG OR IMPROPER
- FALSIFICATION LEADS TO
- POOR PATIENT CARE DUE TO HOSPITAL STAFF BEING MISLEAD ABOUT THE PATIENTS CONDITION
- SOAP
- SUBJECTIVE-WHAT YOU WERE TOLD BY..., OBJECTIVE-WHAT YOU SAW AND FOUND, ASSESSMENT-GENERAL IMPRESSION, PLAN-ACTIONS TAKEN
- WHAT SHOULD BE DOCUMENTED DURING A REFUSAL
- THAT IT WAS AMA, THAT YOU TALKED TO SUPERVISOR OR DOCTOR, YOU TOLD THE PATIENT TO SEE A DOCTOR OR CALL BACK IF NEEDED, HAVE WITNESS SIGN
- CART
- CHIEF COMPLAINT, HISTORY, ASSESSMENT, TREATMENT, TRANSPORT