Documentation and Flow Sheet

Question 1

4 Reasons we document in the Medical Record?

Answer 1

Proof of rendered care
Provides data continuity
Permanent legal record
Communication tool

Question 2

6 occurrences when to chart

Answer 2

1. Change from baseline assessment
2. Change in pt’s condition
3. Procedure or Tx
4. Meds given and Pt response
5. Care plan review & interventions
6. Patient teaching

Question 3

When to document pre-tx safety checks?

Answer 3

BEFORE Pt is hooked up to the machine

Question 4

When to document pre-tx patient data collection/assessment?

Answer 4

Before the start of tx or within 1 hour of PCT hooking pt to the machine

Question 5

When to document observations during tx?

Answer 5

Every 30mins and/or when patients condition declines

Question 6

When to document post-tx data collection/assessment?

Answer 6

When tx is finished

Question 7

What to document when giving meds?

Answer 7

1. Med & Dosage
2. Date & Time
3. Route
4. Reason
5. Patient response
6. Teammate signature
7. Allergies

Question 8

How to document late entry?

Answer 8

Notation, “Late Entry” (if done the day after)

Include the time & date & electronic signature

Question 9

How do you document charting errors?

Answer 9

Draw a single line & note “error entry”, date signature 7 credentials, chart correct information

Question 10

What does SMART communication stand for?

Answer 10

Simple
Meaningful
Actualy
Read
Teach

Question 11

Five W’s to be used when completing an AOR?

Answer 11

Who
What 
Where
When
Why

Question 12

3 Things you shouldn’t include in an AOR?

Answer 12

1. Personal opinions
2. Speculation
3. Vendettas