Review Questions Potter Perry Chapter 26 - Documentation and Informatics Questions and Correct Answers the Latest Update and Recommended Version

Documentation anything written or printed that you rely on as record or proof Accreditation Joint Commission specifies guidelines for documentation Define Diagnosis-realted group (DRG) series of decision trees designed to cluster groups of clients together by diagnosis,surgical procedures, complications, co-morbidities, and age Explain the new rights for clients related to HIPPA client education on privacy protections ensuring client's access to his or her medical records receiving client consent before information is released providing recourse if privacy protections are violated The standards of documentation by the Joint Commission require requires documentation within the context of the nursing process, as well as evidenceof client and family teaching and discharge planning Client record TestTrackers: Unlock Your Exam Potential! | Quality Practice Materials | Boost Your Confidence Today! | Thank You for Choosing Us! © 2024 TestTrackers Customer Support: [] Resources & Updates: [Testtrackers - Stuvia US] Your Success is Our Mission! is a confidential, permanent legal documentation of information relevant to a client'shealth care Reports oral, written, or audiotaped exchanges between caregivers Consultations form of discussion whereby one professional caregiver gives formal advice about the level of care of a client to another caregiver Referrals an arrangement for services by another care provider Communication means by which client needs and progress, individual therapies, client education, and discharge planning are conveyed to others in the health care team Legal Documentation Once of the best defenses for legal claims Financial Billing To determine the accurate and timely reimbursement Education Learning the nature of an illness and the individual client's responses TestTrackers: Unlock Your Exam Potential! | Quality Practice Materials | Boost Your Confidence Today! | Thank You for Choosing Us! © 2024 TestTrackers Customer Support: [] Resources & Updates: [Testtrackers - Stuvia US] Your Success is Our Mission! Research Gathering of statistical data of clinical disorders, complications, therapies, recovery and deaths Auditing Objective, ongoing reviews to determine the degree to which quality improvement standards are met. What are the five guidelines for quality documentation and reporting Factual Accurate Complete Current Organized Factual descriptive, objective information about what a nurse sees, hears, feels, and smells Accurate the use of accepted abbreviations, symbols, and system of measures that are clear andeasy to understand Complete containing appropriate and essential information Current TestTrackers: Unlock Your Exam Potential! | Quality Practice Materials | Boost Your Confidence Today! | Thank You for Choosing Us! © 2024 TestTrackers Customer Support: [] Resources & Updates: [Testtrackers - Stuvia US] Your Success is Our Mission! timely entries; immediate documentation of information as it is collected from theclient Organize