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Crucigrama Sopa de Letras Hoja de Trabajo
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Basics of Documentation

Horizontales
Do not document ________ of time
Do ____ use unapproved abbreviations
Document complete assessment _____
Your _______ may lose funding
Do not give ________
Do not use vague __________
Do not record a ________ without including what you did about it
Be sure to sign off all hand __________ orders
Verticales
_____ in real time
You should _____ read and act upon previous physician and nursing progress notes and orders
Document interventions as well as the _______ of those interventions
If it was documented incorrectly it may be considered __________
If it's not documented It was not ______
Do not _________ for someone else
You can be ________ for malpractice
Poor documentation can ______ your patient