http://www.loc.gov/mods/v3 http://www.loc.gov/standards/mods/v3/mods-3-2.xsd
1 videodisc (23 min., 29 sec.) : sound, color ; 4 3/4 in.
"This program describes commonly used approaches to documentation, a review of the basic data to record in patient records, and practice guidelines to follow that protect patient privacy, comply with federal regulations, and protect the nurse against potential legal actions. After completing this course, the viewer should be able to: describe the functions of medical records, describe five commonly used approaches to documentation, list the most common types of documenting mistakes and sources of inaccuracy, explain the importance of maintaining patient confidentiality, describe strategies to preserve patient confidentiality at all times, explain how to address issues related to noncompliance, unusual occurrence reports and administrative considerations"--Publisher's website.
Functions of medical records -- Types of documentation -- Source oriented documentation -- Problem oriented documentation -- Focus charting -- Charting by exception -- Case management documentation -- Process of documentation -- .Documentation of data collected -- Caveats -- Special circumstances: verbal orders -- Legal aspects of documentation.
Medcom ; consultants: Ruth Kramer, Marguerite Voorhees ; writer: Marcia Wellington.
Executive producer, Rand Rodriguez ; director of photography, Jon Frank.