3.5 Documentation - EXAM 3 with correct
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
answers
List 7 reasons why we need to document and justify
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
our services
||\\||\\
-Communication
-Patient care planning ||\\||\\ ||\\||\\
-Evaluating quality of care ||\\||\\ ||\\||\\ ||\\||\\
-Identifying deficiencies ||\\||\\
-Database for utilization and reimbursement ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
-Research and education ||\\||\\ ||\\||\\
-Legal document ||\\||\\
Types of Documentation: What is subjective?
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
patient reported information ||\\||\\ ||\\||\\
Types of Documentation: what is objective?
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
-Patient hx, systems reviews ||\\||\\ ||\\||\\ ||\\||\\
-Tests & measures ||\\||\\ ||\\||\\
-Results of examination ||\\||\\ ||\\||\\
, Types of Documentation: what is assessment?
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
-Prognosis
-Summary of barriers and impairments ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Types of Documentation: what is plan? ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
-Plan of care ||\\||\\ ||\\||\\
-Goals
What is narrative documentation? ||\\||\\ ||\\||\\ ||\\||\\
handwritten or typed; sentence/paragraph form ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
What is template documentation? ||\\||\\ ||\\||\\ ||\\||\\
handwritten, types, EMR (electronic medical record); ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
has a template made for you to fill in
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
What are 3 general guidelines to documentation?
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
-charting must match charge ||\\||\\ ||\\||\\ ||\\||\\
-avoid extraneous verbiage ||\\||\\ ||\\||\\
-avoid using abbreviations not understood ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
universally by all providers ||\\||\\ ||\\||\\ ||\\||\\
What are the 5 things you should include in
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
documentation?
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
answers
List 7 reasons why we need to document and justify
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
our services
||\\||\\
-Communication
-Patient care planning ||\\||\\ ||\\||\\
-Evaluating quality of care ||\\||\\ ||\\||\\ ||\\||\\
-Identifying deficiencies ||\\||\\
-Database for utilization and reimbursement ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
-Research and education ||\\||\\ ||\\||\\
-Legal document ||\\||\\
Types of Documentation: What is subjective?
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
patient reported information ||\\||\\ ||\\||\\
Types of Documentation: what is objective?
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
-Patient hx, systems reviews ||\\||\\ ||\\||\\ ||\\||\\
-Tests & measures ||\\||\\ ||\\||\\
-Results of examination ||\\||\\ ||\\||\\
, Types of Documentation: what is assessment?
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
-Prognosis
-Summary of barriers and impairments ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
Types of Documentation: what is plan? ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
-Plan of care ||\\||\\ ||\\||\\
-Goals
What is narrative documentation? ||\\||\\ ||\\||\\ ||\\||\\
handwritten or typed; sentence/paragraph form ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
What is template documentation? ||\\||\\ ||\\||\\ ||\\||\\
handwritten, types, EMR (electronic medical record); ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
has a template made for you to fill in
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
What are 3 general guidelines to documentation?
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
-charting must match charge ||\\||\\ ||\\||\\ ||\\||\\
-avoid extraneous verbiage ||\\||\\ ||\\||\\
-avoid using abbreviations not understood ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
universally by all providers ||\\||\\ ||\\||\\ ||\\||\\
What are the 5 things you should include in
||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\ ||\\||\\
documentation?
