Documentation in Healthcare - Worksheet

Front

What does documentation of type of care, time of care, and signature of the person prove?

Back

Interventions were implemented to meet the patient’s needs.

Front

Why is documentation especially significant in managed care?

Back

Institutions are reimbursed only for patient care that is documented.

Front

The nurse charts only additional treatments done, changes in patient condition, and new concerns. What is this system of documentation?

Back

CBE

Front

What form explains the lapse when events are not consistent with facility or national standards of expected care?

Back

Incident report

Front

The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type. This is known as a:

Back

critical pathway.

Front

What makes home health care documentation unique?

Back

Different health care providers need access.

Front

What regulates standards for long-term care documentation?

Back

OBRA

Front

What is the nurse required to do to adhere to the concept of confidentiality for the patient’s medical record?

Back

Have a clinical reason for reading the record.

Front

Documentation is necessary for the evaluation of patient care. Of which phase of the nursing process is this an integral part?

Back

Implementation

Front

What does the nurse use as a basis for documentation in focus charting?

Back

Patient problems