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35 Cards in this Set
- Front
- Back
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Purpose or pt records
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Valuable source of data for Healthcare team -communication -diagnostic and therapeutic orders -care planning -quality process and performance improvement -research and decision analysis -Education -credentialing -Regulation and legislation -reimbursement -Legal and hx doc/ financial record -auditing and monitoring -Quality of care -facilitate patient care |
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documentation
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-Hand written (nurse/physician notes, physical assessment) -Computerized/electronic documentation |
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Confidentiality and what is confidential?
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-Only look in pts chart that you are assigned to All info abt pts written on paper, spoken, saved on computer. Discard paperwork in locked bin, do not destroy medical records **during clinicals do no write pt name on paperwork, never print material |
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Potential breaches in pt confidentiality
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-sending confidential email via public network -Sharing printer amoung units e/ differing fx -discarding copies of pt info in trash cans -Holding conversations that can be overheard -Faxing confidential info to unauthorized persons -Sending confidential messages overheard on pagers |
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Hippa Health Insurance Portability and Accountability Act
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-Protects pts privacy -Confidentiality and compliance w/ Hippa are part of professional practice |
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Standards for documenting
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-Frequency of documentation Q4hrs, wkly, monthly -Records can be used in court if standard are not met DOCUMENT WORK: IF YOU DIDNT DOCUMENT IT DIDNT HAPPEN!!! |
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Interidisciplinary communication within the healthcar team ( 2 ways)
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2. Nursing rpt`oral, written, taped ex. change of shift, telephone, hand-off and incident rpt. |
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Guidelines for quality documentation and rpting (5 important characteristics) FACCO
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Accurate-vitals signs Complete Current Organized |
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Factual: objective info
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Accurately communicate fact and avoids opinions ex. Patient has increased activity and starles easy do not write appears seems apparently ex Pt seems nervous |
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Factual Subjectice info
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-Document the pts exact words in quotations Patient states: "I feel nervous" |
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Accurate
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Avoid generalized empty phrases Lungs sounds are clear in both obes is better that lun sounds are better then yesterday Pt is a febrile VSS vs Pts vital signs T 98.3 oral **correct all errors promptly, draw one single line through the incorrect charting, write omit and initial NEVER CHART OFR ANYONE ELSE |
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Complete
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-Interventions performed -if an rder was questioned/clarified, record that clarification was sought -phone call made/physicians notified |
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Current
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Other health care providers can access the chart and read the nursing actions performed: VS Pain assessments meds given/tx performed Preparation for test/surgery Nurse's notes - change in pts status and who was notified -admission transfer, discharge, or death of a patient -tx/interventions and pts response for sudden change in pts condition ****use 24 military clock for documenting times*** |
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Organized
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-Use black ink pen, not felt or erasable ink -do not use white out -do not leave spaces/blank areas when writing nursing note/progress note -begin each entry w/ date and time -write events inorder -signature and credentials: name/title *Keep pw to your self** |
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Common charting mistakes
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-Health (including allergies) or drug info -nursing actions -meds that were administered -drug reactions -changes in pts condition and the nurses actions -name/credentials of person notified re: change in pt's condition Pt's refusal of med, education regard med refusal and notification of provider -Failing to review documentation of unlicensed personnel -write legibly and complete documentation |
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Methods of documentation Paper or electronic |
-Electronic improves continuity of care -Computerized version of pts medical record |
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methods of documentation
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Narrative note: POMR Progress notes: SOAPIE PIE Focus charting/DAR charting by exception (CBE) |
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Narrative note: POMR |
Problem oriented medical record -database -problem list -care plan -progress note |
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Progress note: SOAP(IE)
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Objective data Assessment; interpretation of subjective and objective data Plan what the caregiver plans to do Intervention Evaluation |
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Progress note: PIE
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Intervention Evaluation -Nurse daily assessment appears on a flow sheet -Continuing problems are documented on daily |
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Progress notes: Focus charting/DAR notes
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Action: nursing intervention Response: of the patient |
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Charting by exception
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-Assesments are standardized on all forms, abnormals are included in a nursing note |
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Common record keeping forms
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-Admission nursing hx form: Guides the nurse through a complete assessment to identify relevant nursing dx or problems -Flow sheets and graphic records: Help team members quickly see pt trends over time and decrease time spent on writing narrative notes -Patient care summary or Kardex: A portable "flip-over" file or notebook with patient information -Standardized care plans: Preprinted , established guidelines used to care for pt who have similar health problems -d/c summary frms -Acuity records |
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Home care documentation
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-Information for insurance `/medicare reimbursement comes from patients medical records/documentation ****nurse must document for reimbursement*** |
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Long term health care documentation
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-Medicare/Medicaid reimburse based on MDS Minimum data set documentation ***Documentation standards/frequency of documentation are set by the government. |
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Reporting: Hand off rpt/change of shift rpt
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-Occurs w/ transfer of pt care -provides continuity and individualized care -Rpts are quick and efficient |
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Reporting: telephone rpts/orders
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-SBAR -Read bak orders to physician/provider*** -Document conversation |
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Incident or occurance rpt
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Document the same indo in the pts chart and incident rpt (DO NOT WRITE NOTE ABT CREATING INCIDENT RPT) |
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Health informatics
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- Goal: to enhance quality and efficiency of care provided to the pt |
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Nursing informatics
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Specialty the integrates nursing science, computer science, and information science to manage and communicate dta, information, and knowledge in nursing practice (ANA) |
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Nursing Information System (NIS
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Clinical Decision Support Systems (CDSSs): Used to support clinical decision makinf Ex. notification of pt allergy during ordering process |
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clinical decision making clinical decision support COPE w/ clinical decision support |
all thing to learn from book |
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Clinical Information Systems
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-order entry system -Laboratory, radiology, and pharmacy systems CPOE: Computerized physician order entry -physicians and practioners enter medication, laboratory, raidiology and tx orders electronically Goal: to maintain pt safety and improve quality of care |
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The nursing process
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Dx: Nursing care plan, critical pathways Planning: Nurse care plan, critical pathways Implementing: flowsheet documentation of interventions Evaluation: Progress note, charting by exception |
