Concepts Cards Perry And Potter Ch 26

Front 1

"Documentation is anything written or printed you rely on as record or proof for authorized persons."

Back 1

"Accreditation agencies such as The Joint Commission (TJC) specify guidelines for documentation. Under the prospective payment system, Medicare reimburses hospitals a set dollar amount for each diagnosis-related group (DRG) (Box 26-1). Everything that is done for a client must be documented in the medical record for the health care institution to recover its costs."

Front 2

"Acuity records offer a way to determine the hours of care and staff required for a given group of clients. A client's acuity level is based on the type and number of nursing interventions (e.g., intravenous [IV] therapy, wound care, or ambulation assistance) required over a 24-hour period."

Back 2

"In some settings a Kardex, a portable “flip-over” file or notebook, is kept at the nurses' station. Most Kardex forms have an activity and treatment section and a nursing care plan section that organize information for quick reference as nurses give change-of-shift reports or make walking rounds. An updated Kardex eliminates the need for repeated referral to the chart for routine information throughout the day."

Front 3

" TJC (2007) has standards for client education necessary for effective discharge planning:

• Instruction in potential food-drug interactions, nutrition intervention, and modified diets

• Rehabilitation techniques to support adaptation to and/or functional independence in the environment

• Access to available community resources

• Under what circumstances clients should obtain further treatment or follow-up care

• Methods of obtaining follow-up care

• The client's and family's responsibilities in the client's care

• Medication instructions, including when to take each medication and why, the dose, the route, precautions, and possible adverse reactions, and when and how to get prescriptions refilled."

Back 3

"Flow sheets are forms that allow nurses to quickly and easily enter assessment data about the client, including vital signs and routine repetitive care, such as hygiene measures, ambulation, meals, weights, and safety and restraint checks"

Front 4

"Nurses are legally and ethically obligated to keep information about clients confidential. Nurses may not discuss a client's examination, observation, conversation, or treatment with other clients or staff not involved in the client's care."

Back 4

"Legislation to protect client privacy for health information, the Health Insurance Portability and Accountability Act (HIPAA), became a final rule in April 2001 and took effect in April 2003. "

Front 5

"HIPAA requires that disclosure or requests regarding health information are limited to the minimum necessary."

Back 5

"Because many individuals will live in this setting for the rest of their lives, they are referred to as residents rather than clients. In long-term care, governmental agencies are instrumental in determining the standards and policies for documentation. The Omnibus Budget Reconciliation Act of 1987 includes extremely significant Medicare and Medicaid legislation for long-term care documentation. Each resident is viewed holistically by using the Resident Assessment Instrument (RAI). A registered nurse who has clinical competence, observational skills, and assessment expertise gathers the RAI. "

Front 6

"In addition, the department of health in each state governs the frequency of written nursing records of the residents in long-term care facilities. "

Back 6

"The case management model of delivering care (see Chapter 2) incorporates a multidisciplinary approach to documenting client care. In many organizations the standardized plan of care is summarized into critical pathways for a specific disease or condition. The critical pathways are multidisciplinary care plans that include client problems, key interventions, and expected outcomes within an established time frame (Figure 26-3)."

Front 7

"A computerized charting system allows for integration of the chart by many disciplines. The nurse and other team members use the same critical pathway to monitor the client's progress during each shift or in the case of home care, every visit. With the computerized record available at every computer terminal, each care provider can access it at any time."

Back 7

"Charting by exception (CBE) focuses on documenting deviations from the established norm or abnormal findings. This approach reduces documentation time and highlights trends or changes in the client's condition "

Front 8

"Narrative documentation is the traditional method for recording nursing care. It is simply the use of a storylike format to document information specific to client conditions and nursing care. "

Back 8

"The problem-oriented medical record (POMR) is a method of documentation that emphasizes the client's problems. Data are organized by problem or diagnosis. "

Front 9

"The database section contains all available assessment information pertaining to the client (e.g., history and physical examination, the nurse's admission history and ongoing assessment, the dietitian's assessment, laboratory reports, and radiological test results)."

Back 9

"After analyzing data, health care team members identify problems and make a single problem list. The problem list includes the client's physiological, psychological, social, cultural, spiritual, developmental, and environmental needs. "

Front 10

"The acronym SOAP stands for: S—subjective data (verbalizations of the client), O—objective data (that which is measured and observed), A—assessment (diagnosis based on the data), P—plan (what the caregiver plans to do). An I and E are sometimes added (i.e., SOAPIE) in some institutions. The I stands for intervention, and the E represents evaluation. The logic for SOAPIE notes is similar to that of the nursing process. Collect data about the client's problems, draw conclusions, and develop a plan of care. The nurse numbers each SOAP note and titles it according to the problem on the list."

Back 10

"The narrative note includes P—problem, I—intervention, and E—evaluation. The PIE notes are numbered or labeled according to the client's problems. Resolved problems are dropped from daily documentation after the nurse's review. Continuing problems are documented daily."

Front 11

"A third narrative format is focus charting. It involves use of DAR notes, which include D—data (both subjective and objective), A—action or nursing intervention, and R—response of the client (i.e., evaluation of effectiveness). One distinction of focus charting is its movement away from charting only problems, which has a negative connotation. "

Back 11

"In a source record the client's chart has a separate section for each discipline (e.g., nursing, medicine, social work, or respiratory therapy) to record data."

Front 12

"A client's record or chart is a confidential, permanent legal documentation of information relevant to a client's health care. "

Back 12

"Reports are oral, written, or audiotaped exchanges of information between caregivers. "

Front 13

"Nurses document referrals (an arrangement for services by another care provider), consultations, and conferences in a client's permanent record so that all caregivers can plan care accordingly."

Back 13

" Nursing informatics is defined by the American Nurses Association (2001) as a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. "

Front 14

"A record is a valuable source of data for all members of the health care team. Its purposes include communication, legal documentation, financial billing, education, research, and auditing-monitoring."

Back 14

"Nurses give a change-of-shift report orally in person, by audiotape recording, or during “walking-planning” rounds at each client's bedside. Oral reports are given in conference rooms, with staff members from both shifts participating. An advantage of oral reports is that they allow staff members to ask questions or clarify explanations. "

Front 15

"An organized report follows a logical sequence."

Note: Change of shift report should include:
Backgorund information

Assessment

Nursing diagnosis/diagnoses

Teaching plan

Treatments (include medical treatments not just nursing interventions)

Family information

Discharge plan

Priority needs

Back 15

"An incident is any event that is not consistent with the routine operation of a health care unit or routine care of a client."

Front 16

"Incident (or occurrence) reports are an important part of a unit's quality improvement program "

Back 16

"To promote continuity of care, you may give transfer reports by phone or in person. When giving a transfer report, include the following information:

1. Client's name, age, primary physician or health care provider, and medical diagnosis

2. Summary of progress up to the time of transfer

3. Current health status (physical and psychosocial)

4. Allergies

5. Emergency code status

6. Family support

7. Current nursing diagnoses or problem and care plan

8. Any critical assessments or interventions to be completed shortly after transfer (helps receiving nurse to establish priorities of care)

9. Need for any special equipment, such as isolation equipment, suction equipment, or traction"

Front 17

"Current TJC standards require that all clients who are admitted to a health care institution have an assessment of physical, psychosocial, environmental, self-care, client education, and discharge planning needs (TJC, 2007). TJC requires documentation within the context of the nursing process, as well as evidence of client and family teaching and discharge planning."

Back 17

"Federal and state regulations, state statues, standards of care, and accrediting agencies set nursing documentation standards. The American Nurses Association's (ANA's) standard of nursing documentation states that “documentation must be systematic, continuous, accessible, communicated, recorded and readily available to all members of the health care team.”"