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1. Define various terms associated with documentation and information systems. 2. Discuss four
purposes of written documentation. 3. Discuss confidentiality of patient records. 4. Discuss the
appropriate uses of the various documentation forms. 5. Identify guidelines for electronic
documentation. 6. Compare source-oriented and problem-oriented documentation systems. 7.
List the common sections of a source-oriented documentation system. 8. Discuss various
methods of charting patient information, including narrative charting. 9. Explain the use and
importance of electronic health records. 10. Describe additional uses for electronic health records
other than documentation of patient care. 11. Discuss variations involved in documentation in
long-term care and home health care. 12. Identify five documentation mistakes that increase the
risk of legal action. 13. Discuss information found in the Connection features in this chapter. 14.
Identify specific safety information.

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1- Define various terms associated with documentation and information.pdf

  • 1. 1. Define various terms associated with documentation and information systems. 2. Discuss four purposes of written documentation. 3. Discuss confidentiality of patient records. 4. Discuss the appropriate uses of the various documentation forms. 5. Identify guidelines for electronic documentation. 6. Compare source-oriented and problem-oriented documentation systems. 7. List the common sections of a source-oriented documentation system. 8. Discuss various methods of charting patient information, including narrative charting. 9. Explain the use and importance of electronic health records. 10. Describe additional uses for electronic health records other than documentation of patient care. 11. Discuss variations involved in documentation in long-term care and home health care. 12. Identify five documentation mistakes that increase the risk of legal action. 13. Discuss information found in the Connection features in this chapter. 14. Identify specific safety information.