P D.pdf
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This document outlines principles and guidelines for effective medical documentation. It discusses that documentation should be comprehensive, of high quality, and track patient outcomes while reflecting current standards. Notes should identify the patient on every page and include date, time, name/initials of the author. The record provides a permanent legal account of care and is used for communication, billing, education, assessment, research, auditing and legal purposes. Requirements include documenting assessments, evaluations, treatment responses and outcomes. Guidelines state documentation should be factual, accurate, complete and current. Examples of documentation formats include progress notes using SOAP, PIECES, or DAR formats. Consequences of inadequate documentation include fragmented care, repeated tasks, delayed therapy and recovery.
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Report writing for the students of Management Sciences
Report writing for the students of Management Sciences
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Discover the Simplified Electron and Muon Model: A New Wave-Based Approach to Understanding Particles delves into a groundbreaking theory that presents electrons and muons as rotating soliton waves within oscillating spacetime. Geared towards students, researchers, and science buffs, this book breaks down complex ideas into simple explanations. It covers topics such as electron waves, temporal dynamics, and the implications of this model on particle physics. With clear illustrations and easy-to-follow explanations, readers will gain a new outlook on the universe's fundamental nature.
Natural birth techniques - Mrs.Akanksha Trivedi Rama University
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Natural birth techniques are various type such as/ water birth , alexender method, hypnosis, bradley method, lamaze method etcDRUGS AND ITS classification slide share
Any substance (other than food) that is used to prevent, diagnose, treat, or relieve symptoms of a
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Let’s explore the intersection of technology and equity in the final session of our DEI series. Discover how AI tools, like ChatGPT, can be used to support and enhance your nonprofit's DEI initiatives. Participants will gain insights into practical AI applications and get tips for leveraging technology to advance their DEI goals.
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An import error occurs when a program fails to import a module or library, disrupting its execution. In languages like Python, this issue arises when the specified module cannot be found or accessed, hindering the program's functionality. Resolving import errors is crucial for maintaining smooth software operation and uninterrupted development processes.
ISO/IEC 27001, ISO/IEC 42001, and GDPR: Best Practices for Implementation and...
Denis is a dynamic and results-driven Chief Information Officer (CIO) with a distinguished career spanning information systems analysis and technical project management. With a proven track record of spearheading the design and delivery of cutting-edge Information Management solutions, he has consistently elevated business operations, streamlined reporting functions, and maximized process efficiency.
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What sets Denis apart is his comprehensive understanding of Business and Systems Analysis technologies, honed through involvement in all phases of the Software Development Lifecycle (SDLC). From meticulous requirements gathering to precise analysis, innovative design, rigorous development, thorough testing, and successful implementation, he has consistently delivered exceptional results.
Throughout his career, he has taken on multifaceted roles, from leading technical project management teams to owning solutions that drive operational excellence. His conscientious and proactive approach is unwavering, whether he is working independently or collaboratively within a team. His ability to connect with colleagues on a personal level underscores his commitment to fostering a harmonious and productive workplace environment.
Date: May 29, 2024
Tags: Information Security, ISO/IEC 27001, ISO/IEC 42001, Artificial Intelligence, GDPR
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Azure Interview Questions and Answers PDF By ScholarHat
Azure Interview Questions and Answers PDF By ScholarHat
How to Build a Module in Odoo 17 Using the Scaffold Method
Odoo provides an option for creating a module by using a single line command. By using this command the user can make a whole structure of a module. It is very easy for a beginner to make a module. There is no need to make each file manually. This slide will show how to create a module using the scaffold method.
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www.StokeNewingtonHistory.com
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A Survey of Techniques for Maximizing LLM Performance.pptx
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A Strategic Approach: GenAI in Education
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
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Azure Interview Questions and Answers PDF By ScholarHat
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A Survey of Techniques for Maximizing LLM Performance.pptx
P D.pdf
- 1. Principles of Documentation Barani Institute of Sciences
- 2. Documentation Principles • Comprehensive and flexible • Quality and continuity • Track patient outcomes • Reflect current standards • Patient identification on every page of the record • Date, time and name/initials, title of the
- 3. Client Record • Permanent legal document • Provides an ongoing account of care
- 4. Purpose of Records • Communicate information accurately, effectively and in a timely fashion. • Financial billing. • Education. • Assessment. • Research. • Auditing. • Legal record.
- 5. JCAHO Requirements • Assessment of needs – Physical – Psychosocial – ENVIROMENTAL – Self care – Client education – Discharge plan
- 6. JCAHO Requirements • Evaluation of outcomes – Response to treatment – Teaching – Preventive care – Client status – Degree of progress – Family involvement
- 7. Guidelines For Documentation • Factual • Accurate • Complete • Current • Organized
- 8. Inaccurate Example • Pt c/o stomach ache. Returned from x-ray 2 hours ago. Dr. Smith called for change in medication order. Ate small amount of breakfast. No relief from pain medication. Up walking in hall, tolerated well. Discharge planner in to talk with family prior to going to x-ray.
- 9. Accurate Example • C/o abd. pain 4/10 RUQ for two hours becoming increasingly worse despite food and fluids. Position change and walking have not helped. Similar to previously dx gallbladder pain. Denies n/v/d or other symptoms. Declines pain meds at this time. VS WNL. I to call if became worse.
- 10. Record Keeping Forms • Nursing history (HX) • Graphic or flow sheet • Medication administration record • Nursing KARDEX • Acuity recording systems • Standardized care plans • Discharge summary
- 11. Narrative Documentation • Problem oriented medical records (PMOR) – Database – Problem list – Nursing care plan – Progress note • Source records
- 12. Progress Notes • Soap(IE) – Subjective – Objective – Assessment – Plan – INTERVETNION – Evaluation • Pie – Problem, intervention, evaluation • Dar: – Data, action, response
- 13. CHARTING BY EXCEPTION: All Standards Are Met Unless Otherwise Documented • Reduces repetition and time • Shorthand for normal findings and routine care • Based on clearly defined standards and criteria • Predefined findings • Predetermined interventions
- 14. Consequences Of Inadequate Documentation • Fragmented care • Repetition of tasks • Delayed therapy • Omitted therapy • Delayed recovery
- 15. Other Forms of Communication • Team meetings -Multidisciplinary team members share information -Members identify problems and solutions • Consultation -One professional gives advice to another
- 16. Patient Report • Nurse to nurse report when providers change. • Nurse to nurse report at change of shift. • Nurse to provider report for change of condition or for instruction. • Diagnostic reports from diagnostic departments (x-ray, lab, etc.).
- 17. Long Term Care Documentation • OBRA act • Documentation – Often done on flow sheets – Less frequently • Caregiver qualifications • Assessments • Individualized care plans – Nursing care must be justified by the documentation
- 18. Computerized Documentation • Legal risk of breaches of confidentiality • Charting errors so nothing is deleted Example of Business Firm
- 19. Contracts Documentation of bylaws Employment agreement Business plan Non-disclosure agreement Compliance and regulatory documents Financial documents Business reports Meeting minutes Business insurance Partnership agreement Contractor agreement Trademark Franchise agreement Online terms of use Board resolutions Company policies Privacy policy How to manage business documents Appoint someone to take charge
- 20. Identify documents Create a document management strategy