- Computerized tracking.
- Patient information sheet – read and sign it!
- Dealing with Violence in the Workplace. This is required training.
- HIPAA Privacy Training requirements http://health.ucsd.edu/compliance/hipaa.shtml
- JCAHO/Department of Health – may visit without warning:
– No food or drinks in patient-care areas.
– Keep patient information confidential: cover charts, close computer screens.
Frequently encountered issues with the dictation system:
- Please remember to dictate your charts before leaving.
- Follow the template (appendix A). Don’t forget:
- Time initially seen:
- ROS, FH, SH (Refer to patient info sheet. State that you reviewed it.)
- PE should include at least vs/ general appearance. HEENT/chest/heart/abd/ext/skin/neuro. (Don’t forget, especially for head trauma patients!)
- Medical course/decision making: Include thought process, related diagnoses, consults, discussion with family/PMD.
CC to PMD