Chapter 3: Documentation Flashcard Review

Question	Answer
Chart (health care record) meets the demands of:	Health Accreditation Medical Insurance Legal Systems
Adding information to chart is called:	Charting Recording *Documenting
Documenting should include:	Type of intervention Time care was rendered *Signature and title of the person providing care is essential
Purposes of Patient Records	Documented communication Permanent record for accountability Legal record of care Teaching *Research and data collection
Patient's chart provides:	Concise, accurate permanent medical record and nursing problems Plans for care Care given The patient's responses to various treatments *Facilitates accurate communication and continuity of care among all members of the health care team
Proper charting covers all areas of patient needs and concerns of:	Physical Emotional Psychological Social *Spiritual
Permanent record is sometimes used by various government and other agencies to:	Evaluate the institution's patient care Justify cost reimbursement for care provided *Establish or Review Accreditation

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	Created by SherieChristina almost 9 years ago