Chapter 17

Front 1

change-of-shift-report

Back 1

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Front 2

charting by exception CBE

Back 2

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Front 3

collaborative pathway

Back 3

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Front 4

confer

Back 4

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Front 5

consultation

Back 5

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Front 6

critical pathway

Back 6

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Front 7

discharge summary

Back 7

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Front 8

documentation

Back 8

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Front 9

electronic medical record MAR

Back 9

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Front 10

flow sheet

Back 10

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Front 11

focus charting

Back 11

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Front 12

graphic sheet

Back 12

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Front 13

incident report

Back 13

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Front 14

minimum data set

Back 14

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Front 15

narrative notes

Back 15

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Front 16

nursing informatics

Back 16

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Front 17

OASIS

Back 17

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Front 18

patient record

Back 18

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Front 19

personal health record PHR

Back 19

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Front 20

PIE charting

Back 20

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Front 21

problem oriented medical record
POMR

Back 21

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Front 22

progress notes

Back 22

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Front 23

referral

Back 23

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Front 24

SBAR communication

Back 24

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Front 25

SOAP format

Back 25

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Front 26

source-oriented record

Back 26

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Front 27

variance charting

Back 27

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Front 28

Documentation

Back 28

- anything written or printed within a patient record
- effective = systematic, timely, accurate, well-written account of nursing care provided to patients
-permanent record of client information and care
- good charting=better care

Front 29

Record

Back 29

- a permanent and legal written communication about the patient's health status
- documentation of the patient history used for educational, research and legal purposes
- used by all members of health team
- contains nursing diagnosis, therapies, signs and symptoms, labs/test

Front 30

Reports

Back 30

- oral, written, or audiotape exchanges of information shared by health care givers
- takes place between two or more people
- can be done face to face, by phone

Front 31

Standards of Documentation

Back 31

- conform to the Joint Commission requirements
- confidential
- written within the context of nursing including: teaching, discharge planning, evaluation of progress, and expected outcomes

Front 32

Joint Commission

Back 32

- accrediting and licensing agency

Front 33

Purpose of Records Documentation

Back 33

- facilitates communication with health care providers
- guides professional and organizational performance improvement
- maintains a legal and financial record of care

Front 34

Legal Documentation

Back 34

- best defense for legal claims
- limits nursing liability when it clearly indicates that individualized, goal directed nursing care was provided to patients based on the nursing assessment

Front 35

Financial Billing

Back 35

- diagnostic related groups DRGs have become the basis for reimbursement
- hospitals are reimbursed a set dollar amount by Medicare for each DRG
- documentation verifies specific nursing care provided to support reimbursement to health care agencies

Front 36

Education in Documentation

Back 36

- learn patterns and anticipate type of care needed
- aids in clinical research: treatment methods, patterns of illness
- Charts are also done for statistics, infection control and research for treatment methods, etc.
-Research may be gathered from studying groups of clients with same disease to compare and contract response to therapies.

Front 37

Nursing Process and Documentation

Back 37

- records provide data used to identify and support plan of care
- initial health assessment provides comprehensive health status
- nursing progress notes detail ongoing assessments as care is provided

Front 38

Auditing and Monitoring

Back 38

- the joint commission requires hospitals to establish quality improvement programs

Front 39

Quality Improvement Programs

Back 39

keep nurses informed of standards of nursing practice to maintain excellence in nursing care

Front 40

Guidelines for Quality Documentation and Reporting

Back 40

- factual
- accurate
- complete
- current
- organized
- accountability

Front 41

Factual Documentation

Back 41

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Front 42

Accurate Documentation

Back 42

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Front 43

Complete Documentation

Back 43

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Front 44

Current Documentation

Back 44

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Front 45

Organized Documentation

Back 45

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Front 46

Accountability and Documentation

Back 46

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Front 47

Clear Nurse Notes

Back 47

- times and dates
- purpose for assessment and intervention are identified
- legible
- is patient quoted directly
- plans are congruent with observations

Front 48

Methods of Recording

Back 48

- narrative
- Problem-oriented medical records
- database
- problem list
- care plan
- progress notes

Front 49

Narrative Charting

Back 49

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Front 50

Database

Back 50

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Front 51

POMR - problem oriented medical records

Back 51

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Front 52

Problem LIst

Back 52

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Front 53

Care Plan

Back 53

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Front 54

Progress Notes

Back 54

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Front 55

SOAP

Back 55

subjective, objective, assessment, plan

Front 56

SOAPIE

Back 56

subjective, objective, assessment, plan, intervention, evaluation

Front 57

PIE

Back 57

problem, interventions, evaluation

Front 58

Chart organization

Back 58

- each discipline has a separate section.. RN, MD, social work, RT, PT, OT
- Advantage: caregivers can easily locate each section
- Disadvantage: records are fragmented

Front 59

Charting by Exception

Back 59

- innovative approach to reduce the time to complete documentation
- only document when something out of the ordinary has been observed

Front 60

Charting by Exception: Advantages

Back 60

- easy to track unexpected changes
- eliminates repetition
- decreases documentation time

Front 61

Charting by Exception: Disadvantages

Back 61

- unable to prove high quality safe care in response to negligence claim made against nursing

Front 62

Focus Charting

Back 62

- allows for documentation for any patient situation
- allows for greater flexibility
- each entry includes data, actions, and patient response to each situation

Front 63

DAR

Back 63

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Front 64

Common Record keeping forms

Back 64

- admission nursing history form
- flow sheets and graphic records
- paient education record
- patient care summary or Kardex
- standardized care plan
- discharge summary form

Front 65

Computerized Documentation

Back 65

- software programs allow you to access data
- info transfered to different reports
- reduction of errors
- standardized care plans
- increased RN productivity

Front 66

Core Measure Protocol

Back 66

- standardized care plans for specific conditions that do require MD orders
- guided by CDC or other agencies
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Front 67

Good Charting Characteistics

Back 67

- legible
- neat, correct
- timely, sequential
- concise, accurate
- correct abbreviations
- stick to facts
- cluster data
- use patients statement
- specific

Front 68

Reports are given

Back 68

- shift change
- PCP upon daily rounds
- PCP upon change in condition
- transfer to new care level
- upon discharge to another facilty

Front 69

Specific Reports

Back 69

- SBAR upon PT status change
- incident report
- sentinel event
- notification of death

Front 70

Documentation Overview 1

Back 70

- accurate, timely documentation is crucial
- med records are legal documents required by state laws & regilation
- communication between caregivers ensuring continuity of care

Front 71

Documentation Overview 2

Back 71

- used for education and research
- substantiate insurance reimbursement claims
- used as evidence in legal proceedings