Term
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Definition
Health insurance portability and accountability act
Provides federal protection for personal health information |
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Term
| Which records are confidential? |
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Definition
| All records, written or electronic, are confidential |
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Term
| What is objective reporting? |
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Definition
| Reporting precisely what you see, smell, feel, or hear. It is the preferred method of reporting |
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Term
| What is subjective reporting |
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Definition
| Records symptoms that only the resident can describe (i.e. pain, nausea) |
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Term
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Definition
| A permanent, legal record of a patients care that includes progress notes, physicians orders, medications, treatments, flow sheets, x rays, and lab reports |
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Term
| What is a resident care flow sheet? |
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Definition
| Detailed list of what needs to be done, including a checklist that must be signed when completed |
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Term
| What should you do if you are unable to complete a task on a patients flow sheet? |
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Definition
| Initial the appropriate space and circle it. Write an explanation on the back of the page and report it to your supervisor |
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