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43 Cards in this Set
- Front
- Back
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characteristics of effective documentation
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consistent w/ professional and agency standards
complete accurate concise factual organized and timely legally prudent confidential |
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the fact way of documenting
must do this |
factual
accurate complete timely |
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fines and punishments for breaking confidentiality of patients
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health insurance portability act & accountability act of 1996.
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2400 hrs
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midnight
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1200 hrs
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noon
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0100
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1 am
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1100
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11 am
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2300
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11 pm
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2100
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9 pm
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0900
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9 am
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1600
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4 pm
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000
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midnight
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should u use abbreviations in pt orders
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no
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what is confidential about pt?
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all information about pt written on paper, spoken aloud, saved on paper
-name, address, phone, fax, soc, reason person is sick, treatments pt receives, info aobut past health conditions -even fact pt is in hospital is confidential -take pt labels off iv bags, etc. before disposing them |
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potential breaches in pt confidentiality
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-displaying info on a public screen
-sendinf confidential email messages -sharing printers among units w/ diff functions -discarding copies of pt info in trash cans -holding conversations that can be overheard -faxing confidential info |
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patient rights
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-see and copy their health record
-update their health record -get a list of disclosures -request a restriction on certain uses of disclosures -choose how to receive health info |
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policy for receiving verbal orders in an emergency
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-record order in pt's medical record
-read back the order to verify accuracy -date and note the time orders were issued in emergency -record VO, the name of the physician followed by the nurse's name and initials |
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policy for physician review or verbal orders
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-reviews order for accuracy
-signs orders w/ name, title, and pager number -date and note time orders signed |
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duties of RN receiving a telephone order
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-record in pt's medical record
-read orders back to a practitioner to verify accuracy -date and note the time orders were issued -record TO, full name and title of physician or nurse practitioner who issued orders -sign the orders with name and title |
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purpose of pt records
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-communication w/ other healthcare pros.
-record of diagnostic and therapeutic orders -care planning -quality of care review -research -decision analysis -education -legal and historical documentation -reimbursement |
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purpose of recording data
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-facilitate pt care
-serves as a financial and legal record -help in clinial research -support decision analysis (legal ramifications, why did u do this?) |
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methods of documentation
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-problem-oriented records
-PIE charting -focus charting -charting by exception -case management model -computerized records -SOAP |
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major components of POMR
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defined database
problem list care plans progress notes |
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formats for nursing documentation
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-initial nursing assessment
-kardex and pt care summary -plan of nursing care -critical collaboratice pathways -progress notes -flow sheets -discharge and transfer summary -home healthcare documentation -long-term care documentation |
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types of flow sheets
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graphic record
24 hr fluid balance record medication record 24 hr pt care records and acuity charting forms |
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change of shift report
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nurses confer
current orders summary of each newly ad. pt report on pt transferred usually done outside pt's room-be aware of who is around |
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methods or reporting
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face-to-face meetings
telephone conversations messengers written messages audio-taped messages computer messages |
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conferring about care
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consultations and referrals (multidisciplinary)
nursing and interdisciplianry team care conferences nursing care rounds |
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3 methods of communication
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documenting, reporting and conferring
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JCAHO
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(Joint Commission on Accreditation of Healthcare Organization 2006)
-specifies that nursing data r/t pt assessment, nursing diagnoses, nursing intervention and pt outcomes are permanently integrated into the pt record. |
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is the only perm. legal document that details nurse's interactions w/ pt and is nurse's best defense in lawsuits.
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pt record
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introduced a new tool to help documentation- "Principles for Documentation" includes policy statements, principles and recommendations to help nurses w/ doc. and comply w/ requirements
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ANA 2003
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each healthcare group keeps data on its own sep. form sections designated for nurses, laboratory, etc.
-disadvantage: data are fragmented. |
source oriented records
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organized around a pts problems rather than sources of info
-progress notes clearly focus on pt problems -# problems and soap it -major parts:defined database, problem list, care plans and progress notes |
POMR problem-oriented medical records
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PIE method
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it is incorporated into the progress notes, prob. identified by #.
problem, intervention, evaluation |
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focus charting
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DAR: data, action, response
-no problem list -any pt concerns |
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charting by exception
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CBE
shorthand method- makes use of well-defined standards of practice; only sig. findings or "exceptions" to these standards are documented in narrative notes |
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case management model
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promotes collaboration, communication and teamwork
-makes efficient use of time -clearly identifies those outcomes that pts are expected to achieve on each day of care -variance charting -collaboratice pathways: computerized doc. system that integrates collaborative pathway and doc. flow sheets designed to match each days expected outcomes. reduces charting time by 40% |
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variance charting
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when pt fails to meet expected outcome-variance from plan is documented.
usual format: unexpeccted event, cause of event, actions taken |
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computerized records
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calls up ad. ass. tool and keys in pt data
-dev. plan of care using NANDA approved diagnoses - |
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minimum data sets
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key component to facilitate data and outcome comparisons
-will use uniform def. to create a common language. 3 categories: nursing care elements, pt demographic elements, service elements. |
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nursing documentation in pt's permanent record includes the following formats:
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-initial nursing ass.
-kardex and pt care summary -plan of nursing care -critical/collaborative pathways -progress notes -flow sheets -discharge and transfer summary -home healthcare doc. -long term care doc. |
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MAR
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medication administered record
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