Question: Documentation And Informatics Worksheet Medical Records: Explain The Use And The Reason 1. Use: 2. Reason: I Guidelines For Effective Documentation: Explain The Characteristics Of Good Reporting 1. Accuracy 2. Thoroughness: 3. Rules 4. What Information Is Confidential? 5. The Purposes Of Patient Records: Explain Each One A. Communication B. Quality/performance…

Documentation and Informatics Worksheet Medical Records: explain the use and the reason 1. Use: 2. Reason: I Guidelines for Effective Documentation: Explain the characteristics of good reporting 1. Accuracy 2. Thoroughness: 3. Rules 4. What information is confidential? 5. The Purposes of Patient Records: explain each one a. Communication b. Quality/performance improvement: c. Accreditation: I d. Auditors/Rescarchers 6. Can a Patient look at their chart, what is the protocol? Methods of Documentation: Explain the following types of documentation, list some advantages and disadvantages of each: 1. Computerized documentation and electronic health records (EHR); 2. SOAP note: what does S-O-A-P stand for? 3. What is Focus charting and when is it done? 2 4. Pie charting, what does P-I-E stand for? 5. What does charting by exception mean? 6. Narrative charting: What is narrative charting and list 10 rules for narrative charting. Rules: list 10 I What is the difference between a Flow sheet and a Graphic record?