Ch. 16 Flashcards
What are purposes of the patient record?
- Communication
- Assessment
- Care Planning
- Legal Document
- Quality Assurance
- Reimbursement
- Research
- Education
What are the principles of documentation?
- Confidential
- Accurate
- Concise and Complete
- Objective
- Organized and Timely
What does CPR stand for?
Universal Computer-Based Patient Record
What is the federally-initiated goal of the CPR?
Having a single health-related electronic record
CPR is supported by who?
2009 Health Information Technology for Economic and Clinical Health (HITECH) Act whose goal is to increase patients access to their health records.
What are components of the CPR?
- Clinical Surveillance Tools (real-time pt. risk scores)
- Handheld devices
- Standardized Vocabulary
What types of nursing progress notes are there?
- Narrative
- SOAP
- PIE
- FOCUS DAR
Explain a narrative note:
?
Explain a SOAP note:
?
Explain a PIE note:
?
Explain a FOCUS DAR note:
?
What ways are Nursing Entries in Patient Records done?
- Flow Sheets
- Plan of Care
- Critical Pathways
Explain Flow Sheets:
Tables for documentation of routine assessments and procedures.
Explain Plan of Care:
Contains nursing diagnosis, goals, outcome criteria, interventions, and evaluation.
(Standardized plans may be used but need to be individualized.)
Explain Critical Pathways:
Multidisciplinary tools that identify expected progression of patient toward discharge.
(Often used for pt.’s with complex care of frequent visits)
