Ch. 18: Documenting and Reporting-MJ Flashcards
The act of recording patient status and care in written or electronic form or in combination of the two forms
Documenting
What other terms are considered documenting?
Documenting, reporting, charting
What should be included in the documentation?
Health history Exams Tests Treatment Outcomes
What is the purpose of documentation?
To provide continuity of care among all team members who provide care to the same patient
Documentation should always reflect the _____
Nursing process
Documentation provides communication between ____-
Providers
Documentation does ____ of care
Continuity
Documentation is an ____ tool and can be used during ____
Education tool; research
Documentation give a _____ of care
Legal document
T/F: Documentation provides quality improvement and reimbursement.
True
What are the 4 advantages of written documentation?
- Familiar
- Does not require a large database networks and is secure to function
- Not dependent on power/electricity
- Inexpensive
What are the disadvantages to written documentation?
- Access may be delayed
- Retrieving info may be slow
- Time consuming
- High risk patient error
- Storage is expensive
- Difficult to protect confidentiality
What are the advantages to electronic documentation?
- Communication is improved among health providers
- Improved access to info
- Saves time
- Improves the quality of care
What are the disadvantages to electronic documentation?
- Expensive
- Electrical issues
- Difficulties with learning
- Lack of integration
What are some examples of common types of charting?
Narrative, PIE, SOAPIER, Focus, Charting by Exception, FACT system, and electronic entry format