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28 Cards in this Set
- Front
- Back
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DOCUMENTATION
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Written communication serves as a permanent record of client information & care.
- client record, info abt current visit or admission for educational, research, & legal purposes |
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REPORTING
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2 or more ppl share info abt client care
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CLIENT RECORD
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Clear, accurate & up-to-date
- contain all assessments, planning, interventions & evaluations for that client |
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Purpose of the
Client Record |
* Communication with other healthcare prof
* Assessment - comparison * Care Planning * Quality Assurance - also reimbursement * Legal documentation - may be used in court * Research - clinical & statistical data * Education |
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Pinciples of Data Entry & Management
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* Accuracy
* Completeness * Conciseness * Objectivity |
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Universal Computer-Based Patient Record
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Centralizatoin of client record to increase acessiblity beyond primary institution
- allowing clients to ahre complete health info w/ any practioner |
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Point of Care
Documentation |
Documentation that takes place as care occurs.
- ↑ efficiency, accuracy, timeliness` |
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Standardized Vocabulary
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Describing practice of nursing, supporting research, identifying cost & effectivenss of nursing interventions
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Nursing Informatics
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Combination of computer science, information science, and nursing science designed to assist in the mgt & processing og nursing data, info & knowledge to support the practice of nursing & delivery of nursing care
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Advantages of Computerized Documentation
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* Stores & retrieves client data fast & easily
* Uses stdized care plans * Charting eligible * Facilitates trasnsmission of info from 1 care setting to another * Improves comm thru' use of std terminology |
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Plan of Care
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Generated at admission & revised to reflect changes in the client's condition
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Client Care Summary
or Kardex |
Document that provides current client information
- patient's demographic info - code status -safety precautions for infections, falls, skin breakdown - basic care needs - treatments & procedures - IV theraphy & blood transfusions - diagnosis & lab tests |
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Nursing Progress Notes
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Recorded for all clients but vary in format depending on setting
- Narrative notes - SOAP note - DAR notes - PIE notes |
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Narrative Notes
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Info written in sentences or phrases; time-sequenced
Adv: Easy to learn, explain in detail Disadv.: Time consuming, difficult to retirieve, unfocused & disorganized |
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SOAP
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S ubjective
O bjective A ssessment P lan Adv.: focuses on identified client problems; interdisciplinary Disadv.: Difficult to master, lengthy |
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SOAPIE
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Subjective, Objective, Assessment, Plan,
Implementation, Evaluation |
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PIE Notes
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Problem, Implementaion, Evaluation
PIE charting simplifies by incorporating plan of care into the progress notes |
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FOCUS DAR Notes
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Data, Action, Response
An entry made on significant event, positive growth, or learning during a teaching session. |
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Flowsheets
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Designed to doc routine nursing procedures and free nurses from writng out continuing procedures repeatedly.
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Charting by Exception
(CBE) |
CBE permits nurse to doc only findings that fall outside the std of care & norms that have been developed by the instituition.
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Critical Pathway
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Used for the care of clients who have specific & generally predictable conditions
Serve as multidisciplinary tool, identifying the expected progression toward discharge. - provide direction abt major interventions to be performed |
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Variance in
Critical Pathway |
Unexpected occurrences that affect the planned care.
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Nursing Discharge Summary
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A nursing discharge plan started at the initiation of care, indicating potential discharge needs & client teaching that will take place.
- notes client's condition @ discharge - provides info about care after discharge |
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Resident Assessment Instrument
(RAI) |
4 Basic Components of RAI
1) Minimum Data Set 2) Triggers 3) Resident Assessment Protocols 4) Utilization guidelines |
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Incident Report
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Any unusual happening, such as fall, medication error, malfunction in equip, or injury to a client, visitor or EE occurs during the performace of healthcare activities.
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S B A R
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Situation
Background Asessment Recommendation |
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What is Confidential?
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All info abt patients written on paper, spoke, saved on computer
- name, address, fax, SS - reason the person is sick - treatments - info abt past health onditions |
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HIPAA
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Health
Insurance Portability and Accountability Act protect patients personal medical info by regulating & dictating processes by which their info is shared. |
