3130 ch. 10 Crossword

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Across
  1. 3. This problem focused documentation style stands for: Subjective data, objective data, assessment, plan, intervention, evaluation
  2. 4. Entries into paper medical records were traditionally made with ______ ink. The date, time, and signature, with credentials of the person writing the entry, were included in the entry. No blank spaces were left between entries because this could allow someone to add a note out of sequence.
  3. 10. the right to be free from intrusion or disturbance in a person's private life.
  4. 11. This abbreviation on the Do not use list can be mistaken as the other letters and instead should be written as 'daily'
  5. 12. This law passed in 1996 focuses on pt privacy and information protection.
  6. 13. Documentation should be factual, accurate, and ________, with proper spelling and grammar.
  7. 15. Medical record documentation should be based on ______.
  8. 16. In the event of _______, the medical record is often the only available evidence of the event in question.
  9. 17. In the case of an emergency a _____ can take a telephone order.
Down
  1. 1. This event is a safety occurrence that affects a patient and causes death, serious permanent or temporary injury, or requires interventions to sustain life.
  2. 2. This i often used by nursing as a hand-off tool and as a structured method for all communications between providers.
  3. 5. The medical record is a document with comprehensive information about a patient's health care encounter, it serves as a major ______ tool between staff members and as a single data access point for everyone involved in the care of the patient.
  4. 6. This report will be filed if a family member fell at the hospital or a pt attempted to hurt a staff member.
  5. 7. real-time process of passing patient-specific information from one caregiver to another or among interdisciplinary team members to ensure continuity of care and patient safety.
  6. 8. This type of charting is chronologic, with a baseline recorded on a shift-by-shift basis. Data is recorded in the progress notes.
  7. 9. patient information held at the nurses' station.
  8. 14. A ______ is a list of ordered medications, along with dosages, routes, and times of administration, on which the nurse initials medications given or not given.