Purposes of Documentation in the Patient's Medical Chart
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, Communication
Legal and historical documentation
Reimbursement
Auditing and Monitoring
Research; data analysis
Education
Why is confidentiality important and how is it maintained?
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It is a legal obligation that ensures the safety of the patient and the
employees. Maintain it by only discussing the patient's diagnosis, treatment,
assessment, and or personal conversations with members of the health
care team directly involved in the patients care
*ALL patient information is confidential
What are some NON-THERAPEUTIC communication techniques?
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Asking personal questions, giving personal opinions, changing the subject,
automatic responses, false reassurance, talking about yourself, asking for
explanations, defensive responses, passive or aggressive responses, and
arguing.
What are guidelines when using touch?
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Give this one a try later!
, Communication
Legal and historical documentation
Reimbursement
Auditing and Monitoring
Research; data analysis
Education
Why is confidentiality important and how is it maintained?
Give this one a try later!
It is a legal obligation that ensures the safety of the patient and the
employees. Maintain it by only discussing the patient's diagnosis, treatment,
assessment, and or personal conversations with members of the health
care team directly involved in the patients care
*ALL patient information is confidential
What are some NON-THERAPEUTIC communication techniques?
Give this one a try later!
Asking personal questions, giving personal opinions, changing the subject,
automatic responses, false reassurance, talking about yourself, asking for
explanations, defensive responses, passive or aggressive responses, and
arguing.
What are guidelines when using touch?
Give this one a try later!
