Purposes of pt record - Study guides, Class notes & Summaries

Purposes of PT record communication care planning quality improvement research education regulation reimbursement legal and historical documentation Characteristics of effective documentation consistent with professional and agency standards complete accurate concise factual organized and timely legally prudent confidential Elements of documentation content timing format accountability confidentiality What is confidential ALL PATIENT INFORMATION Potential breaches in patient confidentiality ...

The Nursing Process/Vital Signs/Documentation/Admission, transfer, discharge (Unitek) Quiz 3&4: Latest Update Graded A+ 5 Purposes for Patient Records 1) Documented Communication 2) Permanent Record for Accountability 3) Legal Record of Care 4) Teaching 5) Research and Data Collection A 65 year old man has a history of emphysema resulting from 30 years of cigarette smoking. He frequently reports dyspnea. What is dyspnea? difficulty breathing A client has not achieved satisfact...

Jurisprudence PT Exam Questions and Answers Already Passed If performed by a person who is adequately trained PT includes.... 1) The design, fabrication, revision, education, and instruction in the use of various ADs 2) The administration of topical drugs that have been prescribed by a licensed health professional authorized to prescribe drugs 3) Physiotherapy: physical measures include massage, heat, cold, air, light, water, electricity, sound, and the performance of test of neuromus...

Discuss the significance and purposes of the medical/dental history Ans- Oral conditions reflect the general health of pt General health factors influence response to treatment The state of the pits health is constantly changing Discuss the reasons for obtaining a medical/dental history prior to treatment Ans- To provide info pertinent to the etiology and diagnosis of oral conditions and total pt care plan. Reveal conditions that necessitate precautions, modification, or adaptations du...

NSC 114 Exam 2 Questions with Complete Solutions Ethical and legal considerations - Answer-- Confidentiality of all patient information - Client's record protected legally as a private record of client's care - HIPAA regulations - Responsibility in using records for the purpose of education and research - dont chart for another nurse - do not leave computer unattended - only look at your pts charts Purposes of Client Records - Answer-*communication - prevents delay in care *plann...

PNR 104 Exam 2 (Answered) Verified Solution Steps of the nursing process in order Assessment, nursing dx, planning, implementation, and evaluation Assessment and nursing DX RN's are responsible for this part of the nursing process Data Collection LPN's main role in nursing process Documentation of the plan Should be constructed right after the admission database is collected. Must be readily available to each nurse who is assigned to the patient. (Reviewed & updated once every 24 hrs.)...

Colorado MPJE Exam Questions and Answers 100% Pass Always pick answer on the stricter law - Correct Answer ️️ -State vs. Federal differ NO Pt info of any kind unless... -- Auth. Pt Rep -- Practitioner -- PharmD -- Intern -- Auth. by law -- Auth. by Pt -- Pharm. Tech -- Police etc. -- Federal Auth. -- Payers Prof. Judge. to release infor to Pt and their Agents. - Correct Answer ️️ -Confidentiality No form of payment from Rx Outlet or PharmD to... -- Providers -- Hx care f...

Florida PT Jurisprudence Exam Latest Update Graded A what is Chapter FS 456? Florida Statues, Health Professions and Occupations: General Provision What is Chapter FS 486? Florida Statues, Physical Therapy Practice Act -laws that govern safe practice in PT in Florida Rule 64B-17 Florida Administrative Code, Physical Therapy Rules - specific rules used to enhance the interpretation of the practice act 486.015: Legislative intent Practice ensures that every physical therapist and physical ther...

Physical Therapy - Evaluation and treatment of a person by physical measures and the use of ther ex, and rehab procedures, with or without AD for the purpose of preventing, correcting, or alleviating any disability. Physical therapy includes: - -Design, fabrication, revision, education and instruction in the use of various AD's including braces, splints, ambulatory, locomotion devices, w/c's, prosthetics and orthotics -Administration of topical drugs that have been prescribed by a licens...

Physical Therapy - Evaluation and treatment of a person by physical measures and the use of therapeutic exercise, and rehabilitative procedures, with or without assistive devices for the purpose of preventing, correcting, or alleviating any physical disabilities. Includes physiotherapy. Physical therapy includes: - - Establishment and modification of PT programs, treatment planning, patient education and instruction, and consultative services - Determining a PT diagnosis in order to treat th...