What are the main purposes of documentation in healthcare?, Preserve patient information, record changes, justify treatment, ensure continuity of care, meet regulatory requirements, support quality control and research, and support reimbursement, Why is documentation important for healthcare professionals?, Protects staff legally, demonstrates good patient care, supports critical thinking, and communicates findings clearly, What does an accurate, complete, and legible medical record imply?, Accurate and organized assessment and management of the patient, What are the four characteristics of a good medical record?, Accurate, complete, legible, and free of extraneous information, What should be documented to ensure accuracy?, Facts and observations only, What should NOT be included in documentation?, Speculation or assumptions, Why must numerical entries be double-checked?, Errors can affect patient safety and legal accountability, What should you do if you make a documentation mistake?, Correct it according to policy and document the error properly, What does “failure to document implies failure to consider” mean?, If something isn’t documented, it’s assumed it wasn’t assessed, What should you do if requested information does not apply?, Document “N/A” or “not applicable”, Why must vital signs be included?, They are essential for every patient assessment, What is a key legal phrase related to documentation?, “If it wasn’t documented, it wasn’t done”, Why is legibility critical in documentation?, Courts rely on records to speak for themselves, What can happen if documentation is illegible?, It may be ignored in legal proceedings, What assumption may be made if charting is sloppy?, That patient care was also sloppy, Why should patients never be labeled in charts?, Labels are subjective and unprofessional, How should patient statements be recorded?, Prefaced with “patient stated” or “per patient”, When should quotation marks be used?, Only for exact word-for-word statements, Why should humor be avoided in documentation?, Medical records may be read by courts and the public, What are the eight basic standards of documentation?, What happened, to whom, by whom, when, where, why, result, and prevention of alteration, What does “what happened” refer to?, A concise description of the event or care provided, What identifies “to whom it happened”?, Patient name and hospital ID number, What identifies “by whom it happened”?, Signature and professional designation, What time format should be used in charting?, 24-hour clock, What should be documented if charting is delayed?, Mark it as a LATE ENTRY, What does “why it happened” include?, Reason for care (routine, MD order, protocol, etc.), What does “result of what happened” include?, Patient response and recommendations, How can handwritten documentation prevent alteration?, Fill or cross out blank spaces and sign the entry, What should be done with electronic documentation?, Save and close before leaving the workstation, What must an RT do if they disagree with an order?, Refuse if not in the patient’s best interest and document why, How should patient refusal be documented?, Date, time, reason, and physician notification, What must RTs do during a cardiac arrest?, Sign the arrest record, What must be documented during patient transport?, Mode of transport and details of transfer, What is prohibited when using electronic medical records?, Accessing charts of patients not under your care, Can you document for someone else?, No, Can you sign someone else’s name?, No, Can you allow someone else to sign your name?, No, Should RTs document diagnostic impressions?, Generally no, When is it acceptable to document an impression?, When within scope and supported by observations, Why must times always be documented?, Omitting time implies lack of concern for time factors, What should be done if a clinical intervention takes a long time?, Document why, What abbreviations should be used?, Only approved institutional abbreviations, Should units be included with numbers?, Always, What should never be used to correct documentation?, White-out or scribbling, Should records ever be altered?, No — they are legal documents, What determines legal protection in healthcare?, Quality of documentation, How long after an incident can malpractice suits occur?, Up to 5 years or more, Why are medical records critical in court?, They are considered evidence, Who owns the medical record?, The facility holds it in trust for the patient, Do patients have the right to view their records?, Yes, Can patients request changes to records?, Yes, or add their version if disagreement exists, How long must records be retained for adults?, At least 10 years after last visit, How long must records be retained for children?, Until age 18, How must confidential records be destroyed?, Shredded or burned, What are the core components of a patient chart?, Assessment, care plan, orders, progress notes, discharge summary, What does SOAP stand for? What is it used for?, Subjective, Objective, Assessment, Plan. Its used for documentation, What is subjective data?, What the patient reports, What is objective data?, Measurable and observable data, What is included in assessment?, Analysis and problem prioritization, What is included in the plan?, Treatment strategy, What does SOAPIER add to SOAP?, Interventions, Evaluation, Revisions, What is narrative documentation?, Paragraph-style charting including subjective and objective data, What is charting by exception?, Documenting only abnormalities, What is a major risk of charting by exception?, “No entry = no care”, What does PIE stand for?, Problem, Intervention, Evaluation, What does FDAR stand for?, Focus, Data, Action, Response, What is SBAR used for?, Patient handovers and transfers, What does SBAR stand for?, Situation, Background, Assessment, Recommendation, What are advantages of electronic charting?, Legibility, auto time/date, access to historical data, secure signatures, Do documentation principles change with EMRs?, No — the same principles apply

week 1 - documentation

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