Defensible Documentation and Therapeutic Media II

Flashcards for Defensible Documentation and Therapeutic Media II

Plaintiff

The person initiating the lawsuit.

Defendant

The person being sued or accused in a lawsuit.

Patient Record

Detailed account of the patient from the time they enter the facility until discharge.

Patient Assessment

Diagnosis of patient by referring MD including special precautions.

Patient Intervention

Details of treatment given, type of procedures, exercises, ADL.

Patient Outcomes

Per visit notes written each time the patient is seen; changes in condition; response to treatment.

POC

Goals stated in functional and measurable terms.

Treatment Parameters

Amount, duration, intensity, repetition, dosage related to treatment.

Discharge Instructions

Instructions given to the patient upon discharge.

PMH

Information regarding patient's past medical history.

Opinions

Documentation should avoid these, focusing on facts instead.

Black

Documentation should be written with this color ink.

Erase

Never do this to correct errors in documentation.

Line

Incorrect entry should be crossed out with a single .

Each

Patient's name, ID number, and claim policy number should be on _ page.

Objective

Use language rather than subjective language.

Apparently, Appears, Seems to be, Tolerated well

Avoid using these subjective terms in documentation.

Objective

Bleeding, pallor, deformities, edema, redness can be examples of _ observations.

Meaningless charting

To describe documentation that is unclear or lacks specificity.

Incident report filed

This should not be documented in the patient's record

Initial assessment

Pt condition on entry into program

Procedure/Ex/ADL

Important to document the amount, duration, intensity, repetition, dosage

Follow-up

Vital to include this in documentation, especially if treatment is abnormal

Chronological Order

Charting events in the order that they occured

Activities of Daily Living

ADL's is the abbreviation for