M13 Quiz prep

Importance of Complete Medical Documentation

It ensures safe, effective care, and provides a clear understanding of a patient's history and treatment.

Consequences of Poor Medical Documentation

Can lead to compromised patient safety, fragmented care, legal issues, and financial repercussions.

What is accurate documentation?

Accurate documentation means every entry should be factual, reflecting what actually happened.

What is complete documentation?

Complete documentation includes all relevant information like assessments, interventions, and patient responses.

Timeliness in Documentation

Documentation should be completed as close to the event as possible for accuracy and detail.

Legible Documentation

Notes must be clear and easy to read, avoiding ambiguous jargon or abbreviations.

Organized Documentation

Information should be structured logically to follow the patient's story easily.

Confidentiality in Documentation

Patient privacy must be maintained at all times with appropriate security measures.

Proper Correction of Documentation Errors (Written)

Draw a single line through errors, label it as 'Error,' initial and date it, then write the correct information.

Proper Correction of Documentation Errors (Electronic)

Use specific EHR features for amendments and track corrections while viewing the original entry.

Source-Oriented Charting

Organizes information by the healthcare discipline that generated the note.

Problem-Oriented Charting (POMR)

Organizes the chart around the patient's identified problems in four sections: database, problem list, initial plan, and progress notes.

Advantages of Source-Oriented Charting

Easy to locate information within a specific discipline.

Disadvantages of Source-Oriented Charting

Can lead to fragmented care, making it difficult to see the overall patient status.

Advantages of Problem-Oriented Charting

Promotes a holistic view and facilitates communication across disciplines.

Disadvantages of Problem-Oriented Charting

More time-consuming to set up and requires consistent use of the problem list.

Advantages of Narrative Charting

Provides a detailed chronological account of the patient's experience.

Disadvantages of Narrative Charting

Can be lengthy, disorganized, and hard to retrieve specific information.

Advantages of Charting by Exception (CBE)

Reduces charting volume by documenting only deviations from established norms.

Disadvantages of Charting by Exception (CBE)

Requires well-defined standards and may lead to omissions.

SOAP Charting

A structured format for progress notes including Subjective, Objective, Assessment, and Plan.

Example of Subjective Data in SOAP

'Patient reports a persistent dull ache in their lower back, rated a 6 out of 10.'

Example of Objective Data in SOAP

'Temperature 98.6°F, heart rate 78 bpm, blood pressure 120/80 mmHg.'

Assessment in SOAP

Interpreting the data collected to identify the problem, e.g., 'Likely lumbar strain secondary to heavy lifting.'

Plan in SOAP

Outlines action to take following assessment, e.g., 'Continue with heat therapy and ibuprofen.'

SOAPIE Charting

Extends SOAP with Intervention and Evaluation sections.

Intervention in SOAPIE

Details specific actions or treatments implemented for the patient.

Evaluation in SOAPIE

Describes the patient's response to the interventions.

Advantages of Computerized Charting Systems

Improved legibility, accessibility, reduced errors, and enhanced data analysis.

Disadvantages of Computerized Charting Systems

High implementation costs, technical issues, and potential for data entry errors.

Advantages of Personal Health Records (PHR)

Improved access to medical information, enhanced communication, and increased patient engagement.

Methods to Prevent Cyber Attacks

Use strong passwords, regular software updates, firewalls, and employee training on cybersecurity.