Basic nursing chapter 9
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Anything written, or printed within a patient record
What is a flow sheet?
documents on which frequent observation, or spacific measurements are ordered
What does JACHO stand for?
joint comission on acfredidtation fro hospitals and orginizations (created the JACHO do not use list..)
What does HIPPA stand for?
Health Insurance portability and accountability act.
What is a DRG?
Diagnosis- related groups. basis for establishing reembersement for patient care
What are five common malpractice issues?
- Failure to doccument the correct time/date of events
- Failure to record verbal orders/signing orders
- Charting actions in advance to save time
- Documanting incorrect data
- Failing to give a report or to give an incomplete report to an ongoing shift
Name three methods of documentation
- Nerritive- tells a story
- PODR problem oriented medical record -
- Charting by acception- normal, normal, abnormal.
What is PERLA?
- rates the alertness of a patient ( associate with eyes )- -
- Oriented times 1,2,3 .. 1-person 2-place 3-time.
What would you like to do?
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