PSYC 3430 Lecture Notes - Lecture 17: Electronic Signature, Debt Management Plan, Blood Pressure
13 Jan 2020
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Proposed treatment (aim, reference options that were considered, recommended treatment, expected side effects, do not assume major knowledge) Progress notes: used by all health care professionals to document progress of their patient in reverse chronological order and must record all important findings, assessments, recommendations and interventions made. Also called medication/prescription orders and come in many formats: Verbal order given to a licensed transcriber. A standard order set, signed by the prescribing practitioner. Recall that an order set is evidence based medicine and used to prescribe certain conditions and procedures accordingly and are developed by the institute for safe medication practice (ismp). All medications being taken must be listed along with dose, frequency, start/stop dates, and any special administration instructions. The administering practitioner must record the exact times of admin. Missed doses must be recorded as well with a reason given as to why (refused, nausea,
