Ch 26

Front 1

4 types of progress notes are:

Back 1

1. P.I.E. - Problem, Intervention, Evaluation
   
2. S.O.A.P. - Subjective Data, Objective Data, Assessment, Plan
3. S.O.A.P.I.E - Subjective Data, Objective Data, Assessment, Plan, Intervention, Evaluation
4. D.A.R- Data, Action, Response

Front 2

What is H.I.P.A.A?

Back 2

Health - Insurance - Portability & Accountability - Act

To protect patient privacy of health information. It governs all areas of patient information and the management of that information.

Front 3

What is a Report?

Back 3

A written document of the results of a medical examination & includes:

• Hand-off

• Telephone
• Incident/Occurrence

Front 4

What is a Record?

Back 4

Is anything written or printed on which you rely on for proof of the patients actions & activities

Front 5

What is a Consultation?

Back 5

Speaking with other medical personnel regarding a patients needs, or asking for advice on patient care

Front 6

What is a Referral?

Back 6

An arrangement for services by another care provider.

Front 7

Hand-Off Reports:

Back 7

• Occurs with transfer of patient care
• Provides continuity & individualized care
• Reports are quick & efficient
  

Front 8

Telephone Reports & Orders:

Back 8

• Includes SBAR
• Document every call
• Read backs
  

Front 9

What is SBAR?

Back 9

Component of a telephone report that incudes:

S- Situation

B- Background

A- Assessment

R- Recommendation

Front 10

What is a read back?

Back 10

Reading back to other person on the line what you heard them say and wrote down

Front 11

Incident or Occurrence Reports:

Back 11

• Used to document any that is not consistent with the routine operation of a health care unit or the routine care of a patient
• Follows agency policy
  

Front 12

Legal guidelines for recording:

Back 12

• Correct all errors promptly using correct method
  
• Record all & only facts - no personal opinions
• Do not leave blank spaces in nurses notes
• Write legibly in permanent ink
• If an order was question, record that clarification was sought
• Chart only for self, not for others
• Avoid generalizations
• Begin each entry with date & time
• End each entry with signature & title
• Keep computer password secure

Front 13

Paper Recording:

Back 13

• Episode oriented
• Key information may be lost from one episode of care to the next

Front 14

Electronic Health Records (EHR)

Back 14

• A digital version of a patients medical record
• Integrates all of a patients information in one record
• Improves continuity of care
  

Front 15

Narrative recording:

Back 15

Is a traditional method when a nurse records what the patient has reported

Front 16

Problem Oriented Medical Record (POMR)

Back 16

• Database
• Problem list
• Care Plan
• Progress notes
  

Front 17

Admission Nursing History Form:

Back 17

Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems

Front 18

Flow Sheets/Graphic Records:

Back 18

Helps team members quickly see patient trends over time and decrease time spent on writing narrative notes

Front 19

Patient Care Summary (Kardex)

Back 19

A portable flip-over file or notebook with patient information

Front 20

Standardized Care plans

Back 20

Preprinted, established guidelines used to care for patients who have similar health problems

Front 21

What is an Acuity Record?

Back 21

Record useful for determining the hours of care & staff required for a given group of patients.

Front 22

Communication purposes of records?

Back 22

Allows health care team members to understand patient needs and progress, know their individual therapies, the content of consultations, patient education & discharge planning

Front 23

What is the purpose of legal documentation of records?

Back 23

One of the best defenses for legal claims associated with nursing care. Limits nursing liability when all nursing care information is indicated specifically and clearly.

Front 24

The purpose of records for reimbursement:

Back 24

Involve Diagnosis-Related Groups (DRG's) and are the basis for establishing reimbursement for patient care.

Front 25

The purpose of education for records is:

Back 25

Records include a variety of information such as:

• Diagnosis
• Signs/Symptoms
• Successful or Unsuccessful therapies
• Diagnostic findings
• Patient behaviors

Front 26

Research and Records:

Back 26

After appropriate agency approval, patient records are used for research studies

Front 27

Records and Auditing/Monitoring:

Back 27

Records are used to identify deficiencies in nursing and to help quality improvement

Front 28

Pertinent information to include in discharge teaching?

Back 28

• Medications
• Diet
• Community resources
• Follow up care
• Emergency contact information
• Contact information for questions
  

Front 29

Factual guidelines for quality documentations & reporting:

Back 29

Descriptive, objective information about what a nurse sees, hears, feels and smels

Front 30

Accurate guidelines for quality documentation & reporting:

Back 30

Uses exact measurements to establish accuracy; concise data is clear and easy to understand

Front 31

Complete guidelines for quality documentation & reporting:

Back 31

Contains all appropriate & essential information; describes nursing care administered and the patients response.

Front 32

Current guidelines for quality documentation & reporting:

Back 32

Documentation is recorded in a timely manner.

Activities/Findings documented at the time of occurrence are:

• Vital signs
• Pain assessments
• Administration of medications/treatments
• Diagnostic testing or surgery
• Pre-Op checklist
• Change in patient status
• Admission, transfer, discharge or death of patient
• Treatment for sudden change
• Patients response to treatment or intervention

Front 33

Organized guidelines for quality documentation & reporting:

Back 33

Information is communicated in a logical order

Front 34

What are critical pathways?

Back 34

Interdisciplinary care plans that include patient problems, key interventions, & expected outcomes within an established time frame

Front 35

What is a case management model?

Back 35

Incorporates an interdisciplinary approach to documenting patient care using critical pathways

Front 36

Current documentation standards:

Back 36

Require each patients have an assessment including:

• Physical
• Psychosocial
• Environmental
• Self-Care
• Patient education
• Knowledge level
• Discharge planning needs

Front 37

Nursing documentation standards:

Back 37

Set by federal & state regulation, state statutes, standards of care & accreditation agencies

Front 38

Home Care Documentation:

Back 38

• Medicare specific guidelines for eligibility establishment is the basis for home care documentation
• Documentation is the quality control & justification for reimbursement from medicare, medicaid or private insurance
• Nurses need to document all services to receive payment

Front 39

Long Term Health Care Documentation:

Back 39

• Governmental agencies are instrumental in determining standards & policies
• Omnibus Reconciliation Act of 1987 includes medicare & medicaid legislation for documentation
• Dept. of Health governs frequency of written nursing records
  

Front 40

Health Informatics definition:

Back 40

Defined by the American Medical Informatics Association (AMIA) as "The application of computer & information science in all basic & applied biomedical sciences to facilitate the acquisition, processing, interpretation, optimal use & communication of health related data

Front 41

Health Informatics purpose:

Back 41

• Focus on the patient & process of care
• Goal is to enhance the quality & efficiency of care provided
• Driven by the Health Information Technology for Economic & Clinical Health Act (HITECH)
  

Front 42

Nursing Informatics:

Back 42

1. Is a specialty that integrates nursing science, computer science, & information science to manage & communicate data, information & knowledge in nursing practice
   
2. Supports the way nurses function & work
3. Supports & enhances nursing practice through improved access to information & clinical decision-making tools

Front 43

Nursing Informatics designs:

Back 43

• Nursing process design follows protocol or critical pathway design
  
• Clinical decision support systems (CDSSs) are used to support decision making

Front 44

Health Care Information System (HIS)

Back 44

A group of system used in a health care organization to support & enhance health care

Front 45

Nursing Informatics Advantages:

Back 45

• Increased time to spend with patients
• Better access to information
• Enhanced quality of documentation
• Reduced errors of omissions
• Reduced hospital costs
• Increased nurse job satisfaction
• Compliance with requirements of accrediting agencies
• Development of common clinical databases
  

Front 46

Nursing informatics responsibilities:

Back 46

• Privacy, confidentiality & security mechanisms
  
• Handling & disposal of information
• Protection of the confidentiality of patients health information & the security of computer systems
• Top Priorities include:

1. Log in processes
2. Audit trials
3. firewalls
4. data recovery processes
5. Policies regarding the handling & disposal of data to protect patient information

Front 47

2 major types of information systems:

Back 47

1. Clinical Information Systems (CISs)
   
2. Computerized Provider Order Entry (CPOE)

Front 48

Clinical Information Systems:

Back 48

• Monitoring systems
• Order entry
• Laboratory systems
• Radiology systems
• Pharmacy systems
  

Front 49

Computerized Provider Order Entry (CPOE)

Back 49

• Improves accuracy
• Speeds up implementation
• Improves productivity
• Saves money