intervention - ANSWER care provided to improve a situation
Charting, recording, documenting - ANSWER the Process of adding
information to a chart is called
Documentation - ANSWER is an integral part of the implementation
phase of the nursing process and is necessary for the evaluation of
patient care and for reimbursement for the cost of care provided
DRG - ANSWER diagnostic related group a group that classifies
patients by age, diagnosis, surgical procedure, and other information
with 25 major diagnostic categories and hundreds of different
subcategories
basics rules of documentation - ANSWER all documents should have
the correct patient name identification number, date of birth, date and
time if appropriate
Basic rules for documentation - ANSWER avoid use of general empty
phases such as status unchanged or had good day
basic rules for documentation 3 - ANSWER be objective in charting:
only what you hear, see, feel, smell
basic rules for documentation 4 - ANSWER Be timely, specific,
accurate, and complete
basic rules for documentation 5 - ANSWER Chart after Care is
provided, not before
basic rules for documentation 6 - ANSWER chart all ordered careas
given or explain the deviation, ex. NPO, nothing by mouth, for
laboratory, off unit, refused
, basic rules for documentation 7 - ANSWER chart as soon and as often
as necessary
basic rules for documentation 8 - ANSWER Chart facts avoid
judgmental terms and placing blame.
basic rules for documentation 9 - ANSWER Chart only your own care,
observations, and teaching, never chart for anyone else.
basic rules for documentation 10 - ANSWER Describe each item as
you see it
Basic rules for Documentation 11 - ANSWER Document only what you
observe not opinions, never use charging to accuse someone else
Basic rules for documentation 12 - ANSWER Fill all spaces leave no
empty lines chart consecutively go line by line do not Left margin.
Basic rules for documentation 13 - ANSWER Follow each institution's
policy and procedures for charting
Basic rules for documentation 14 - ANSWER Follow rules of grammar
and punctuation
Basic rules for documentation 15 - ANSWER If a charting error is
made, identify the error according to the facility's policy and make the
correct entry.
Basic rules for documentation 16 - ANSWER If you question and order
record that clarification was sought
Basic rules for documentation 17 - ANSWER Note patient response to
treatments and response to analgesics or other special medications
Basic rules for documentation 18 - ANSWER Sign each block of
charting or entry as directed by the agency policy
Charting, recording, documenting - ANSWER the Process of adding
information to a chart is called
Documentation - ANSWER is an integral part of the implementation
phase of the nursing process and is necessary for the evaluation of
patient care and for reimbursement for the cost of care provided
DRG - ANSWER diagnostic related group a group that classifies
patients by age, diagnosis, surgical procedure, and other information
with 25 major diagnostic categories and hundreds of different
subcategories
basics rules of documentation - ANSWER all documents should have
the correct patient name identification number, date of birth, date and
time if appropriate
Basic rules for documentation - ANSWER avoid use of general empty
phases such as status unchanged or had good day
basic rules for documentation 3 - ANSWER be objective in charting:
only what you hear, see, feel, smell
basic rules for documentation 4 - ANSWER Be timely, specific,
accurate, and complete
basic rules for documentation 5 - ANSWER Chart after Care is
provided, not before
basic rules for documentation 6 - ANSWER chart all ordered careas
given or explain the deviation, ex. NPO, nothing by mouth, for
laboratory, off unit, refused
, basic rules for documentation 7 - ANSWER chart as soon and as often
as necessary
basic rules for documentation 8 - ANSWER Chart facts avoid
judgmental terms and placing blame.
basic rules for documentation 9 - ANSWER Chart only your own care,
observations, and teaching, never chart for anyone else.
basic rules for documentation 10 - ANSWER Describe each item as
you see it
Basic rules for Documentation 11 - ANSWER Document only what you
observe not opinions, never use charging to accuse someone else
Basic rules for documentation 12 - ANSWER Fill all spaces leave no
empty lines chart consecutively go line by line do not Left margin.
Basic rules for documentation 13 - ANSWER Follow each institution's
policy and procedures for charting
Basic rules for documentation 14 - ANSWER Follow rules of grammar
and punctuation
Basic rules for documentation 15 - ANSWER If a charting error is
made, identify the error according to the facility's policy and make the
correct entry.
Basic rules for documentation 16 - ANSWER If you question and order
record that clarification was sought
Basic rules for documentation 17 - ANSWER Note patient response to
treatments and response to analgesics or other special medications
Basic rules for documentation 18 - ANSWER Sign each block of
charting or entry as directed by the agency policy
