Title: Perform patient-related and administrative documentation.
Course: Respiratory Therapy I (14061-I) > Section: Developing Effective Communication and Patient Care Skills

Performance should include a demonstration and explanation that reflect a working understanding of the following:

- Medical writings are legal documents.
- All documentation should be accurate, complete, legible, timely, and recorded/stored according to the policies of the healthcare facility.
- Patient-related documentation may include medication, orders, progress notes, and patient history. Administrative documentation may include computerized integrated information systems and a picture archiving communication system (PACS).

Process/Skill Questions:

- How does the principle of “the right procedure/right patient/right exam every time” influence medical documentation?
- Under what circumstances should a respiratory therapist question a patient order?
- What are the differences between computerized information systems and PACS?