Pasrr Level Ii Psychiatric Evaluation 2019-2024 Form

Instructions and help about PLEASE PRINT AND DO NOT USE ABBREVIATIONS

hi i'm kathy lehmann i'm an occupational therapist at fmh crestwood and i'm here to talk a little bit about documentation you need to make sure that you sign date and time every note when you finish it and also do not use abbreviations that are on the do not use abbreviation list as nurses most of our documentation is now done by entering information directly into meta tech or on another computer system like centricity these systems automatically record the date and time of our entries but when it comes time to document on paper we all need to remember to sign date and time every entry and while i'm talking about documenting in the medical records do not use any of the unapproved abbreviations qd cc u and mso4 are the ones we see most often and the ones the joint commission found on their recent visit more importantly these and other unapproved abbreviations have been known to contribute to patient safety errors so please use only approved abbreviations and when it comes to a paper rec