what report documents patient dosing

What is a CT dose report sheet?

In conclusion, the CT dose report sheet contains detailed technical information about each CT study. This information can be used to estimate doses, optimize protocols, troubleshoot image quality issues, and satisfy regulatory requirements. 1. The Joint Commission website.

What information should be entered in the patient record?

Only clinically pertinent incident related information should be entered in the patient record. Put time and date on all entries in the medical record. Notes should be contemporaneous. Label added information as addendum and indicate when it was entered.

What are the documentation and reporting requirements in nursing?

Documentation and reporting in nursing are needed for continuity of care it is also a legal requirement showing the nursing care performed or not performed by a nurse. 1. Source – Oriented Record Example: the admissions department has an admission sheet; the physician has a physician’s order sheet, a physician’s history sheet & progress notes 2.

How to document medical information well?

Clinical documentation | How to document medical information well. 1 1. It’s a form of communication. Good documentation promotes continuity of care through clear communication between all members involved in patient ... 2 2. It’s a legal document. 3 3. It’s a document of service.

Update Medication Date

We seem to get a number of requests to correct medication dates due to dosing errors. Sometimes it is an entire patient that was missed or a single take home. The ability to edit medication records is a right that needs to be assigned to a role in the role configuration.

Destroy Medication

From time to time situations arise where medication needs to be removed from a patient record. Whether they have returned with their take homes because they are changing medications or a patient may present with a police report that their take homes were stolen.

Reprint Label

Dymo label printer troubles? Every once in a while, it will malfunction, and your label does not print properly. You can now navigate over to the patient dosing info page and click reprint next to the dose and have a label printed.

Immunization Information Systems

Immunization information systems (IISs) are confidential, computerized databases that record and consolidate information on all vaccine doses administered by participating providers.

The Vaccine Adverse Event Reporting System (VAERS)

The Vaccine Adverse Event Reporting System external icon (VAERS) is a national vaccine safety surveillance program. Health care professionals are encouraged to report any adverse events that occur after the administration of any vaccine licensed in the United States.

What is nursing documentation?

Nursing documentation is responsible for keeping the legal record of the patient, which is known as the patient’s chart, regarding his personal information and care. On the other hand, nursing reporting occurs when two medical professionals directly and indirectly involved in the care of the patient collaborate and exchange information about ...

Why is the record used in healthcare?

The record can be utilized to assess the healthcare quality provided to the patient and the competency of the healthcare provider.

What are the functions of the patient’s chart?

It serves as a well-organized process of relaying necessary information from one care provider to another. It imparts important data about the patient’s condition.

What is Kardex sheet?

Kardex. It is an organized and concise sheet regarding the patient’s information and care used during endorsements. It is available to all the healthcare providers involved in the patient’s care.

Why do you put horizontal lines on a nurse's notes?

Place horizontal lines on spaces to avoid others from inserting additional data on the nurse’s notes.

What is noted instead of the patient's feelings?

Behaviors are noted instead of the patient’s feelings.

How to write a chart?

It is not necessary to use complete sentences in charting. For each entry, begin with a capital letter for the first letter of the initial word and end the statement with a period. 2. Permanence or Proper Usage of Ink. Use a ball pen when writing any information on the chart.

Why is documentation and reporting important in nursing?

Documentation and reporting in nursing are needed for continuity of care it is also a legal requirement showing the nursing care performed or not performed by a nurse.

What is a database in health care?

Database – consists of all information known about the client when the client first enters the health care agency. It includes the nursing assessment, the physician’s history, social & family data

Why is the traditional client record important?

It is convenient because care providers from each discipline can easily locate the forms on which to record data and it is easy to trace the information.

What is a flow sheet?

FLOW SHEET – uses specific assessment criteria in a particular format, such as human needs or functional health patterns

What is progress note?

Progress Notes – chart entry made by all health professionals involved in a client’s care; they all use the same type of sheet for notes.

What is the key to clinical documentation?

Therefore, the key to excellent clinical documentation is the ability to know exactly what is relevant to document. Couple this with being able to succinctly summarise and report main issues and you will document medical information well.

How to document what a patient tells you about how they are feeling?

It is important to document what the patient tells you about how they are feeling, in their own words. Use quotations if appropriate, using quotation marks. Objective. Here, you should document objective, repeatable and measurable facts about the patient’s status.

How to document a consult?

Make sure to document the relevant patient identifiers and medical background. And then, succinctly summarise or list the current issues during admission. Most importantly, document the clear clinical question that is being posed to the consulting team. Leave your full name and contact details for the team to contact you.

How to document a meeting?

Begin by documenting exactly who is present in the meeting, and their roles. For example, family members, medical staff, social workers. Document if a translator is present for the meeting. List each point as it is raised, and the general decisions that are made about each point. Use quotations where relevant, using quotation marks. Summarise the key agreements that were made at the conclusion of the meeting. Then, clearly document a plan forward. Whether there has been a change in the patient’s treatment plan, or whether it is for ongoing discussion at a later stage.

Why is documentation important in healthcare?

Good documentation promotes continuity of care through clear communication between all members involved in patient care. The medical record is a way to communicate treatment plans to other providers regarding your patient. This ultimately ensures the highest quality of patient care.

Why is clinical documentation important?

First, understanding the critical importance of good documentation is key. There is so much more to documentation than mere legal protection. Medical records are a crucial form of communication. And the importance of complete, accurate, concise, timed and dated documentation cannot be overstated.

Why is documenting a family meeting important?

Documenting a family meeting can be challenging due to the unstructured and conversational format. However, clear documentation is especially crucial in this setting as key management discussions often take place. These conversations can change the course of a patient’s care.

What is the dose report sheet for CT scans?

In addition to basic hospital information and patient demographics, the sheet contains specific information for each series (i.e., scan) acquired during the study. This information typically includes tube voltage (kV), average tube current (mA) and rotation time (s) or their product (tube current–exposure time product [mAs]), average volume CT dose index (CTDI vol ), phantom size used to calculate CT dose index (CTDI), and dose-length product (DLP). The tube voltage, tube current and rotation time (or tube current–exposure time product), and CTDI vol parameters are checked to ensure that the patient was scanned correctly and to determine if any changes were made by the technologist at the time of the study (e.g., increasing the tube voltage for a large patient). These parameters may also be useful when troubleshooting image quality problems or optimizing protocols. The list of series is often checked to determine if any series was skipped or was not sent to the PACS. The series list also allows us to identify retakes, which are usually performed because of patient motion.

What Is the CT Dose Report Sheet and Why Is It Useful?

All modern CT machines produce a sheet that contains extensive data related to the CT study. How do we interpret and use the data that this sheet contains?