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)
When does patient handoff occur?
Occurs any time one provider transfers the responsibility and accountability for the care of a patient to another.
What is a Joint Commission Goal?
All agencies have standardized pt. handoff.
When may verbal communication/handoff occur?
- Change of shift
- Telephone
- Consults
- Rounding
- Care plan conference
What is SBAR?
- Situation: What is happening at present time?
- Background: What are the circumstances leading up to this situation?
- Assessment: What is the problem?
- Recommendations: What should be done to correct the problem?
When is SBAR commonly used?
When RN feels there has been a change in pt. status.
What is a change to improve communication?
TeamSTEPPS
Team Strategies and Tools to Enhance Performance and Patient Safety
What is TeamSTEPPS
A safety curriculum to improve pt. outcomes and promote teamwork among healthcare providers.
What are some of TeamSTEPPS communication tools and strategies?
- SBAR
- Call-out
- Check-back
- Handoff
- CUS
