Ch. 15 Documentation Flashcards
Electronic health record (EHR)
- Enhances communication among health care providers and thus patient safety
- Helps to avoid admissions and delays in care
Personal Information Protection and Electronic Documents Act (PIPEDA)
federal organization
-applies to all commercial organizations not just health care
Records or chart:
Confidential permanent legal document
Reports:
Oral, written, audio-recorded exchange of information
Consultations:
A professional caregiver providing formal advice to another caregiver
Referrals:
Arrangement for services by another care provider
Narrative
The traditional method (story-like format)
Problem-Oriented Medical Record
Database
Problem list
Care plan
Progress notes
SOAP
SOAPIE
Subjective data—objective data—assessment—plan
Subjective data—objective data—assessment—plan—intervention—evaluation
PIE
Problem—intervention—evaluation
Focus charting (DAR)
Data—action—response
Source records
A separate section for each discipline
- nursing will have it’s own section, doctors another. It’s easy to find your own section but the details could be in many dif sections so hard to find the information
Charting by exception (CBE)
Focuses on documenting deviations
- only chart when something unusual happens . If everything is going as usual then no note is written
Variance
is present when the activities on the critical pathway are not completed as predicted or the patient dies not meet the expected outcomes
Standardized care plans
std guidelines to treat patients with similar diagnosis. It doesn’t leave a lot of room for patients unique needs.
Acuity ratings
- determine the hours of care and number of staff required for a given group of patients every shift or every 24 hours.
- For example, in an acuity system, bathing patients is classified from 1 (very independent) to 5 (totally dependent in all aspects of care).
- There will be a lower staff-patient ratio in a med nursing situation then in a nursing home
Change-of-shift reports
Transfer of accountability practice guidelines Background information Assessment Nursing diagnosis Teaching plan Treatments Family information Discharge plan Priority needs
(I-SBAR-R) technique
Identification—situation—background—assessment—recommendation—read back
Health informatics
The combination of clinical practice, information management/information technology, and management practices to achieve better health
Informatics
Not just computer competency
Ability to use evolving methods of discovering, retrieving, and using information in practice
Critical Thinking
- Recognition that an issue exists, analyzing information, evaluating information, and drawing conclusions
- Use of evidence-informed knowledge and the clinical decision-making process
Inference:
making education guesses. Looking at the meaning and patterns and make an guess
Basic critical thinking
following procedure step by step without adjusting to patients unique needs. No thinking ot processing. Can be memorized. Ex. Cather insertion
Complex critical thinking:
Nurse learns that a problem may have more than 1 or conflicting solutions. Ex. Diabetse, normally we’d give short acting insulin 30min before a meal. Maybe in this case their blood sugar is 3.5 and they’re not planning on eating a meal.
Commitment
you make a decision and you stand by it
Critical Thinking Synthesis
A reasoning process by which you use knowledge, reflect on previous experience, and integrate professional practice standards to provide competent, ethical nursing care
