an accurate and legible patient care report quizlet

How accurate is my Patient Care report?

The accuracy of your patient care report depends on all of the following factors, EXCEPT: A) including all pertinent event times. B) the severity of the patient's condition. C) the thoroughness of the narrative section.

What is the clinical documentation in a patient's record?

The clinical documentation in a patient's record forms the basis for current and future care of that patient by the healthcare provider. The documentation in the record will be relied upon by clinicians in the healthcare provider setting to make decisions regarding the patient's care.

What should be included in the patient care report?

The patient care report: A) provides for a continuum of patient care upon arrival at the hospital. B) is a legal document and should provide a brief description of the patient. C) should include the paramedic's subjective findings or personal thoughts. D) is only held for a period of 24 months, after which it legally can be destroyed.

Why is it important for the patient's medical record to contain?

Therefore, it is important for the patient's medical record to contain detailed, complete, and accurate documentation in the event that the document is needed as evidence in any legal proceeding.

What does a patient care report ensures?

The patient care report is a medical document that is used to record the care that a patient has received. This report is used to ensure that the patient has received the best possible care and to make sure that the patient is receiving the correct care.

What is the purpose of Nemsis quizlet?

The National Emergency Medical Services Information System (NEMSIS): collects relevant data from each state and uses it for research.

When a competent adult patient refuses medical care it is most important for the paramedic to quizlet?

When a competent adult patient refuses medical care, it is MOST important for the paramedic to: ensure that the patient is well informed about the situation at hand.

Which of the following prefixes means pertaining to a gland?

prefix Latin, pertaining to a gland—e.g., adenoid.

What is the purpose of Nemsis?

The National Emergency Medical Services Information System (NEMSIS) is the national database that is used to store EMS data from states and territories. NEMSIS is a universal standard for how patient care information resulting from an emergency 911 call for assistance is collected.

Who is allowed to revise a PCR quizlet?

Only the person who wrote the PCR can revise it.

Which of the following would be the most significant complication associated with incorrect use of medical terminology?

Which of the following would be the MOST significant complication associated with incorrect use of medical terminology? Ineffective treatment could be rendered.

Which of the following scenarios reflects a violation of Emtala?

Which of the following scenarios reflects a violation of EMTALA? A hospital transfers an unstable patient to another facility. If a mentally competent adult refuses emergency medical treatment, your FIRST action should be to: try to determine why he or she is refusing treatment.

Which aspect of the Hipaa is most pertinent to the paramedic?

Which aspect of the HIPAA is MOST pertinent to the paramedic? If your EMS system receives a subpoena for a patient's protected health information, it would be MOST appropriate to: notify legal counsel before releasing any information.

What are the 5 basic word parts of medical terminology?

Medical terms are built from word parts. Those word parts are prefix , word root , suffix , and combining form vowel .

What does PUR mean in medical terms?

Pelvic-Urethra Reflex (biology)

What is the suffix pertaining to eating or swallowing?

Suffix: -phagia. Suffix Definition: eating; swallowing.

What sort of organisms would you instruct investigators to test for plague?

If your doctor suspects plague, he or she may look for the Yersinia pestis bacteria in samples taken from your: Buboes. If you have the swollen lymph nodes (buboes) typical of bubonic plague, your doctor may use a needle to take a fluid sample from them (aspiration).

Which statement correctly describes the normal microbiota of the skin?

Which statement correctly describes the normal microbiota of the skin? The skin's normal microbiota are capable of growth at elevated salt concentrations.

Which of the following describes the instrumental value of a species?

Which of the following defines the instrumental value of a species? Species are valuable because they exist, Species provide us with sources of new genes for crops, Species provide us with nuts to sell, and Species are beautiful to look at. instrumental value of cod.

Why do we use extracted reports in clinical?

Practices also report that they utilize extracted reports on patient and disease registries to track patient care as well as facilitate quality improvement discussions during clinical meetings.

How does electronic health record improve health care?

Electronic health records (EHRs) can improve health care quality. EHRs can also make health care more convenient for providers and patients.

Why are EHRs important?

EHRs Can Be the Foundation for Quality Improvements. Reliable access to complete patient health information is essential for safe and effective care. EHRs place accurate and complete information about patients' health and medical history at providers' fingertips.

What is documentation in healthcare?

Documentation is a form of communication that provides information about the healthcare client and confirms that care was provided. Accurate, objective, and complete documentation of client care is required by both accreditation and reimbursement agencies, including federal and state governments. Purposes of documentation include: • Carrying out professional responsibility.

Where should the client's name be on a lab report?

The client’s name and other identifying information, such as client identification number, should be on every page of every document in the client’s record or any other documents, such as laboratory reports.

What is flow sheet?

Flow sheets are a component of all other types of documentation. They may vary considerably in format, but usually involve some type of vertical columns or horizontal rows as well as graphs in order to record date, time, assessments, interventions, and outcomes. Flow sheets may require check marks or initials to indicate that actions were done. Leaving something blank indicates it was not completed, so it’s important to fill the flow sheets out completely. Often abbreviations are used because of the small space for writing, and these may be indicated by a legend at the top or bottom of the sheet. The purpose of flow sheets is to reduce the time needed for charting and to eliminate redundancy; however, flow sheets do not replace nursing notes completely. Sometimes nurses repeat in the progress notes information that is already in the flow sheets, creating unnecessary duplication, and creating lengthy progress notes that lack purpose.

What is client records?

Client records are legal documents, so any documentation should be written in clear standard English with good grammar and spelling to prevent misinterpretation. Slang or non-standards terms not be used.

Why should there be no blank spaces in nursing notes?

No blank spaces should be left in charting because this could allow others to make later additions or alterations to the nursing notes. A straight line must be drawn through any empty space on a line.

What happens if a nurse forgets to chart a medication?

This is not actually true: even if a nurse forgets to chart a medication, the medication was still given. However, if there is a legal action and the chart is examined, there is no evidence that the medication was given as ordered, and a nurse that admits to carelessness in documenting has little credibility. Further, if a medication that is not ordered is given in error, failing to chart it doesn’t mean it didn’t happen. It means that the nurse has compounded a medical error with false documentation by omission, for which there may be serious legal consequences.

Why is it important to document client records?

Client records are often very complicated with numerous sections, but it is important that documentation be done on the correct form so that the information can be retrieved and used by others.

What are the tensions surrounding nursing documentation?

These include: the amount of time spent documenting;13–15the number of errors in the records;9,16,17the need for legal accountability;18–20the desire to make nursing work visible;21and the necessity of making nursing notes understandable to the other disciplines. 22, 23For the purposes of this review, we confine ourselves to discussions of either manual or automated nursing systems of documenting patient care, primarily in hospitals. As we have found, while there are good and well-designed individual studies, the different methodologies, populations studied, and variables analyzed have led to little generalizability across the research, making comparisons between them impossible.

What is nursing documentation?

Nursing documentation covers a wide variety of issues, topics, and systems. Researchers, practitioners, and hospital administrators view recordkeeping as an important element leading to continuity of care, safety, quality care, and compliance.4–7Studies, however, reveal surprisingly little evidence of the linkage between recordkeeping and these outcomes. The literature features multiple exhortations and case studies aimed at improving nurses’ recordkeeping in general8–10or for specific diagnoses.11, 12

How much time do nurses spend on documentation?

Other studies have exposed the overall documentation burden carried by nurses. Hardey and colleagues31found that recordkeeping was given lower status and priority than was direct patient care. It was also viewed as excessively time consuming. Nurses regularly copied data from the medical record and other documents to create personal records that guided their activities. Korst and colleagues13conducted a work-sampling study over a 14-day period. Out of 2,160 observations, the average percent of time nurses spent on documentation was 15.8 percent; 10.6 percent for entry on paper records and 5.2 percent on the computer. The percentage of time spent on documentation was independently associated with day versus night shifts (19.2 percent vs. 12.4 percent, respectively). Time of day is also a factor in retrieving information.

What is information work in nursing?

Information work is a critical part of the medical endeavor. Strauss and Corbin3note that trajectory work, as they view medical care, requires information flow before and after each task or task sequence to maintain continuity of care. Tasks are not isolated but are intertwined and build on one another to achieve patient goals. Nurses bear a large burden in both managing and implementing the interdisciplinary team’s plan for the patient, as well as documenting the care and progress toward goals. As a result, nurses spend considerable amounts of time doing information work. There are several genres of nursing documentation studies: those that examine recordkeeping practices as a whole, those that examine issues relating to the documentation (time, content, completeness), and comparative evaluations of different types of changes in the documentation regime including automation versus paper. Taken together, these provide both detailed and broad knowledge of nurses’ recordkeeping practices and highlight the reasons why any change (manual or computerized) is so difficult to integrate into nursing practice.

Why is documentation important in healthcare?

A primary purpose of documentation and recordkeeping systems is to facilitate information flow that supports the continuity, quality, and safety of care. Since recordkeeping systems serve multiple purposes (e.g., legal requirements, accreditation, accountability, financial billing, and others), a tension has arisen and is undermining the primary purpose of the record and instead fueling discontinuity of care, near-misses, and errors. Among the more specialized types of documentation is the plan of care, a requirement of the Joint Commission.1, 2Though planning and plans should facilitate information flow across clinician providers there is little generalizable evidence about their effectiveness.

What are the issues with EHR records?

In several more targeted studies, the central issues of concern were how well the records reflected the care given and accuracy of the patient’s condition. Tornvall and colleagues33audited EHR records and found that reports of medical status and interventions were more prevalent than nursing status. The authors concluded that nursing documentation was limited and inadequate for evaluating the actual care given. Ehrenberg and Ehnfors’34triangulation between data from a chart review and interviews of nurses revealed little agreement between the records and the care nurses reported as having given. The researchers went so far as to state in their findings (p. 303) that “there are serious limitations in using the patient records as a data source for care delivery or for quality assessment and evaluation of care.”34

How does care planning improve outcomes?

In research where the intervention has focused on changing the care planning process, findings have shown that patient outcomes can be improved. Implementation of a care pathway for post surgical patients , to streamline nursing care of postoperative colon resection patients, resulted in a statistically significant shorter length of stay.52In another controlled study, From and colleagues53found that new care planning forms, as opposed to a narrative written in the medical record, could be associated with earlier recognition of patient problems, a shorter length of stay, and a higher accuracy in planning the discharge time.

What is a C billing system?

C) is a nationwide billing system that any EMS provider can use.

Do insurance companies pay if unapproved abbreviations are used?

D) insurance companies do not pay if unapproved abbreviations are used .

What is the first piece of documentation that appears on a patient's record?

The patient's history and physical is one of the first pieces of documentation that appears on the patient's record. This document usually includes not only information pertaining to the patient's history, but more importantly, pertinent information regarding the patient's current condition. Here, the attending physician should document his/her assessment of the patient's current condition. It is possible that the attending may be working with symptoms and differential diagnoses at the time of the history and physical exam. It is important that s/he document these symptoms and any differential diagnoses in the history and physical. Although these conditions may be eliminated once a definitive diagnosis has been established, it is important to understand (and have documented) what the physician was working with in terms of initial or "working" diagnoses. This information can be used to substantiate any tests or consultations that are ordered during the stay.

Who provides documentation in the patient's record?

In the majority of inpatient cases, other physicians, in addition to the attending physician provide documentation in the patient's record. These may include consultants, anesthesiologists, and pathologists in the case of patients undergoing surgery. This may also include radiologists and cardiologists responsible for interpreting diagnostic test results. Let's address these documents individually.

What is clinical documentation?

Clinical documentation in a patient's record includes any and all documentation that relates to the care of the patient during the patient's stay or encounter. In the inpatient setting, some of the important pieces of inpatient documentation include:

What is the role of an attending physician in a patient's record?

It is the responsibility of the attending physician to determine the relevance and importance of all other documentation in the patient's record.

Why is it important for an attending physician to document the reason why an order is made?

Without this direction from the attending physician, the team attending to the patient would be frozen. From a documentation perspective, it is important for the attending physician to document is the reason why an order is made. This information provides complete detail for the actions of the physician in reference to the patient's condition.

How has the healthcare system changed?

Along with this trend, we have seen fewer, but more severe inpatient admissions and an increase in outpatient admissions over the past decade. Second, from an information management viewpoint, there has been an increasing trend toward computerization of medical records. The government has responded to this trend by implementing privacy and security protections through HIPAA legislation. Third, reimbursement to healthcare providers for services has evolved. Many of the initial changes were triggered by HIPAA legislation as well. These began with the Medicare fraud and abuse initiatives of the 1990s and have continued through the present with CMS policy updates focusing on physician documentation.

What is documentation in billing?

Documentation is the key to appropriate billing. In each case, documentation forms the basis for coding and the eventual bill that is submitted for a patient's care.