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31 Cards in this Set
- Front
- Back
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DRG |
- Diagnosis related groups - Cost reimbursement by government - Classifies patient by age, diagnosis, surgical procedure, and other information to predict the use of hospital resources including length of stay - Only reimbursed for documented care - Ex) medicaid, Medicare |
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Incident report |
- document any event not consistent w/ the routine operations of a health care unit or routine care of patient - ex) nurse neglects to give meds, or gives incorrect dosage - helps prevent future problems through education and other corrective measures - should be objective - should never admit fault - should never be mentioned when charting |
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Quality Assurance (QA) |
- audit in health care that evaluates services provided and results achieved compare with acceptable standards - Only means institution has to prove that they are providing care to meet patients needs |
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Discharge forms |
- begins at admission - patient and family should be involved - provides important, concise, and instructive communication for continuity of care - written documentation |
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Managed care |
- systematic approach to care that provides framework for the coordination of medical and nursing interventions usuing clinical (critical) pathways |
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Clinical (critical) pathways |
- allow staff from disciplines to develop standardized integrated care plans for a projected length of stay for patient of a specific case type - case types usually occur in high volume and are predictable |
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Objective vs. Subjective data |
- objective: perceived by examiner ex) sees, hears, measures, and feels - subjective: descriptive data |
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SBAR(R) |
S - situation B - background A - assessment R - reccomendation (R) - read back Method of communicating among health care providers as part of documentation. Helps prevent errors during hand off |
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SOAPIER |
S - subjective data O - objective data A - assessment P - plan I - intervention E - evaluation R - revision SOAPE: shortened version. Action taken included with planning |
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Methods of record |
- traditional chart - narrative charting - problem oriented medical records - focus charting - charting by exception - record keeping forms |
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Traditional charting |
Divided into sections/blocks. Emphasis placed on specific sections of info Ex) admission information, physicians orders, progress notes, etc (non computerized) |
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Narrative charting |
- Descriptive observations, care, and responses. - Can be used for computerized and non computerized data. - can be subjective or objective - abbreviated story form |
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Problem oriented medical records |
- according to scientific problem solving method - used to identify and prioritize problems - list form - ex) use of flow sheets, soap, soapier |
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Focus charting |
Modified list of nursing dx used as index for nursing documentation (not problem lists) - ex) POMR charting - focuses on positive concepts of patient needs rahter than medical dx problems - ex) DARE |
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Charting by exception |
- chart at beginning of shift - during shifts only notes made are for additional treatments - detailed flow sheets |
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Record keeping forms and examples |
Eliminate need to duplicate data repeatedly in nursing notes - kardex: centerslized/concise. Kept at nursing station part of EHR/EMR - nursing care plan: plan that outlined proposed nursing care based on the nursing assessment and nursing dx to provide continuity of care |
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Use of proper body mechanics |
- helps prevent injury - should be followed by health care personel and patient - maintain proper body alignment - wide base support - bend knees and hips. Not back - use large muscle groups - stand directly in front of pt/object your working with - carry objects close to body - use assistive devises. |
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ROM |
-active: or does independently - pasive: nurse helps pt - passive-active: pt does with nurse |
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SRD |
Safety reminder devices -used to immobilize a pt or part of pt body such as arms or hands - long term facilities tend not to use as much - leads to increased aggitation, anxiety, and feeling of helplessness -disoriented, agressive, and pts on drugs more likely to use are - require doctors order - inform patient and family |
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Nursing process |
Assessment Nursing dx Outcomes Implementation Evaluation |
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Discharge planning |
-ideally begins shortly after admission - involves pt and family - provides resources to meet limitations - focuses on improving long term outcomes -provide clear instructions for continuity of care |
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Semi fowler |
30 degrees |
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Orthopneic |
Sitting at 90 degree angle with head resting on table - used with patient with respiratory or cardiac conditions |
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Sims |
Side laying Used for suppository |
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Prone |
Face down Body aligned |
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Genupectoral |
Knee chest. |
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Lithotomy |
Giving birth |
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Trandelenburg |
Legs above head |
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Lifting |
- when lifting use large muscle groups (arms, shoulders, hips, thighs) - the use of more muscle groups will distribute workload more evenly |
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Electronic health record |
- support data analysis necessary for coordinating patient care - eliminates repetativeness - increase efficiency and decreases cost - more legible - research and quality asurance - EHR: echange pt data within facility and with other facilities -EMR: exchange pt data within facility only |
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Charting |
- clear, concise, accurate, and complete - correlate with medical orders, kardex info, and nursing care plan - chart only your own care - document what you observe, no opinions - if charting error is made identify error then make correction - when making late entry note as late entry then proceed with entry. |
