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What is the reason information is entered in a chart? - ANS_Communication between all hospital staff and to chart irregularities from bas lines What are the guidelines for effective documentation? - ANS_Consistent with professional and agency standards Complete, Accurate, Concise Factual Organized and Timely Legally Prudent Confidential What are the measures to protect confidential client information? - ANS_1. Only persons authorized by the health care facility director may gain access 2. The medical record shall document any consent to treat, all exams, diagnoses. services , and follow-up indicating the date, name of patient, name of the service providers, and description of the service. The provider of the service shall sign the record 3. When not in use medical record all be stored in either locked or in a locked room 3 to keys to medical files and/or record room shall be limited to those university yees authorized by the health facility's director to have such access 3. To ensure the medical records are filed, stored, and utilized in a manner that provides maximum confidentiality, each health care facility shall review bianrually its record management procedures What is the purpose of client records? - ANS_1.Communication 2.Planning client care 3.Auditing health agencies (making sure health agencies are meeting the clients standards) A.Research ducation 6.Reimbursment 7. Legal documentation 8.Health care analysis (may assist health care planners to identify agency needs such as over utilized or underutilized hospital services) How do we apply SBAR when communicating with other health care professionals? - ANS_SBAR provides a consistent method for hand-off communication that is clear, structured, and easy to use for professionals to be able to hand off information and be on the same page with ease in regards to patient care. Narrative - ANS_*T ype of source-oriented records Description of pertinent observations of patientt.: 1. TE patient’s responses to nursing ca are statements that specify nursing care, including teaching. received by patient and 1. Statements that describe patient's condition and progress. or lack thereof, toward recovery and goal achievement ul. Descriptions of patient complaints and how patient is coping or failing to cope with them, and murs: SSPONSE -Address routine care, normal findings, and patient problems identified in care plan -description of the status of problem, related nursing interveritions, patient responses. needed revisions to care plan *ATRA (Assessment, Intervention. Response, Action) or DARA (Date, Action, Response, Action) Source record - ANS_A paper format in which each health care group keeps data on its own separate form. Notations entered chronologically, the most recent entry being near the front. 
