Ch 19: Documenting and reporting Flashcards
What is the biggest no no in regards to the active documenting
NEVER Document before doing
What does communication enable personnel to do and avoid
How do nurses communicate
Communication is enables personnel to support and complement one another
-avoid duplication and omission in care
Nurses communicate through documenting and reporting
IS LEGAL DOCUMENT
What are some of the purposes of patient records
***Communication #1 diagnostic and therapeutic orders care planning “ activities” quality process and performance improvement research, decision analysis education credentialing reimbursement legal and historical documentation
If it wasn’t documented it wasn’t what
if you don’t document what do you not get what is not given
If it wasn’t documented it wasn’t done
If you don’t document you don’t:
- get reimbursement
- you don’t give care
What kind of record does documenting become (allows)
- what other kind of record does it serve
- what does it support
 Give another name for patient record
What does the joint commission require to be in the patient record
Documenting of care becomes a record that allows quality in evidence-based care
- Becomes financial/legal Record
- supports decision analysis
Patient record = PHI
The joint commission requires all ADPIE+ needs to be in the patient record
If allegations are brought against a nurse what does a patient’s record act as
Where are two of the most common issues with documentation
 What kind of adherence prevents errors
Other than a legal document if allegations the patient record is the best defense for a nurse
Two of the most common issues with documenting:
- Omission
- in accurate entries
Adherence to documenting guidelines prevent errors
 what are elements of documentation
- content type
- timing (not what)
- to policy
-  ()what must you do to all of your documentation
- Private
Elements of documentation:
-all content must be
COMPLETE, CONCISE, CURRENT, FACTUAL
-must be done in time and matter
not early not late!!
- format following policy
- accountability sign all documentation
- Confidential
 What information is confidential give a few examples
Give a few examples of breach of confidentiality
ALL INFO IS CONFIDENTIAL
-anything written, computer, spoken, address phone/fax,SSN
BREACHES🚫🚫 -giving info by mistake -discussing in public -leaving computer unattended -Sharing/exposing passwords • do not share with anyone -improper accessing, reviewing, releasing • if it doesn’t pertain to you you don’t need to find out

What kind of standard does HIPAA set in for for what
Give the name for HIPPA
HIPPA sets national center for security of electronic protected health information
HIPAA = health insurance portability and accountability act
What patient rights do patients have according to HIPAA
Info in record modify List of  request Receive
See and copy their health records
Update their health record
Get a list of disclosures (who read record)
Request a restriction on certain disclosures (seeing)
Choose how to receive information
As a student in a facility what do you assume in regards to patient information
What can policies indicate
- often
- routine care
- ID self
- short words
- handling
What is one of the goals of the National Patient Safety goal
As a student in a facility you assume the responsibility to keep all patient information confident
Policies may indicate
- frequency of entries
- if routine care is recorded
- identification after making entry
- abbreviations to use
- How to handle errors
A National Patient Safety goal is to avoid using the do not use list
What must you have a clear understanding of that can be charted by a UAP and an RN
-Give an example
What is the general rule regarding documentation
You must have a clear understanding of which assessment and interventions can be documented by UAP and RN
-I&O, vitals, glucose
General rule of documentation:
-only document the assessment and intervention you perform
What is the absolute most important purpose of a patient record 
What care is fostered with communication
What is one of the actions you can do but checking the record
What must you keep in mind in regards to what is documented in the patient record
The most important purpose of a patient record is for communicating with the healthcare team and providing info to others
Communication fosters CONTINUITY of care
By checking the record you can see if the
Dr has spoken with the patient or family
-DNR, Full code
Keep in mind doctors and others can make judgments about a nurses contribution to the healthcare team partially based on what is documented in the record

When are diagnostic studies ordered what is the results help do
What has been the source of many errors in regards to notes in chart
-what does electronic record provide among communication
If you cannot understand what is written what do you not want to do
-When in doubt what
- diagnostic studies ordered since patient admission
- diagnostic study results help order care for patient
Illegible hand written notes having the source of many errors
-electronic records give clear communication
 if you cannot understand NEVER GUESS! ➡️When in doubt, call
Why is there an effort to minimize verbal orders
 What is the only circumstance a doctor may give a verbal order
Who must the order be given from and to who
What is our job as nurses when given a verbal order

There’s an effort to minimize verbal orders due to errors
ONLY IN EMERGENCIES Can verbal orders be given
-otherwise written
Order must be given DIRECTLY No no from Dr to RN
Our job as nurses when given a verbal order is to read back what was interpreted in the verbal order
What is the policy for reviewing verbal orders in emergencies -in med record -Read -what do you record when issued -whose names belong on the order -review for -sign with   What MUST The order be
Record in medical record ASAP
Read back to verify
Date and time order issued
Record verbal order + name of physician issuing+ nurses name
Review for accuracy
sign orders with name, title
 date the note and time orders signed
Orders MUST BE SOGNED BY DOC 

What kind of care does the EHR provide well creating what
What is the doctor considered as in regards to evidence what does it help continue
EHR provides higher quality/safer care for patients while creating tangible enhancements for organization
Dr. considered primary source of evidence to continue Measure performance versus pre-determined standards
What are a few things and nurse can do in an EHR
- use tools /admin tools
- develop care plan
- add to documentation
- review list of treatment, protocols, meds
- immediately document care
- provide higher quality safer care
What do person health records contain
What can a patient give for providers to view record
Give and describe the two types of personal health records
Personal health records contain medical history, diagnosis, symptoms, meds
Patient make your password to personal health record so provider can review
 Type of personal health record:
- Standalone personal house record
- patient fills in own info
- the info then stored on patient’s computer or Internet - Tethered/connected personal health record
- EHR
- linked to specific healthcare organization/information system
 what does the health information exchange (HIE) allow
What are the benefits of HIE
- vehicle for
- Basic level of
- simulate what
- helps public officials do what
- loop for
- deployment of
- Backbone of and four
HIE allows access and securely sharing a patient’s vital medical information electronically and to give the best care possible
Benefits of HIE:
-vehicle for improving quality and safety of patient care
- provide basic level of inter-operability among each other
- simulate consumer education and patient involvement in own healthcare
-  helps public officials meet commitment to community
- loop for feedback between research and practice
- facility to efficient deployment of emergent technology and services
- gives backbone for technical infrastructure for leverage by initiatives
Describe the methods of documentation
Source orientant Problem oriented PIE charting Focus charting  Chart by exception Case management model  EHR
Source oriented:
-EACH provider keeps data on its own SEPERATE FORM
Problem oriented med record
- SOAP
- organizes around patient problem
PIE charting
- problem
- intervention
- evaluation
Focus charting
-brings focus of care back to patient concerns
Charting by exception:
- documenting ONLY Out of ordinary
- makes use of well defined standards of practice
Case management model
-collaborative between disciplines

Define progressive note
Defined the narrative note
progress note:
-informs caregiver about patient progress
Narrative note:
-written to routine care, normal findings, patient problems
What is the problem oriented medical record =?
-define
Give the components of the problem oriented medical record
- Is a defined what
- List of what
- what kind of plan
- what kind of notes
- give the format and define
Problem oriented medical record = SOAP
•def: organize around patient problem
- Defined database
- problem list
- care plan
- progress notes
- SOAP format
S-ubjective O-bjective A-ssessment P-lan 
Describe a few formats for nursing documentation
Initial nursing assessment
care plan
critical collaborative pathway
progress notes
Initial nursing assessment:
-nursing history + physical assessment
Care plan “ patient care summary”
-common problem + diagnosis
Critical collaborative pathways
-detail standardize care plan
Progress notes
Describe a few formats for nursing documentation
Flow sheets and graphic records medication administration records (MAR)
acuity record
discharge and transfer
summary long-term care and home health care documentation
Flow sheet and graphic records:
- document routine care
- graphic records = vitals record
Medication administration records: -
-meds
Acuity record:
-document 24 hours and rinks patient acuity
Discharge and transfer summary

Long-term care and home health care documentation
What kind of documentation is a flow sheet
What are the different types of flow sheets:
Flowsheets: routine care
Graphic records: vitals 24 hour fluid balance record MAR 24 hour patient care record Acuity record
What are Medicare requirements for home healthcare (Who is eligible?)
- still need
- good/dying
- is the patient stable?
What must we ensure in those who have home health care
Patient is homebound and still needs skilled nursing care
Rehab potential is good (or patient is dying)
Patient status is not stable
We must ensure patient’s making progress and expected outcomes of care
What does the RAI (resident assessment tool) help us know
What are the four basic components of RAI (resident assessment tool)
The RAI Helps us know if the patient belongs in a nursing home
- minimum data set
- gives screening, clinical, functional status - Triggers:
- specific resident response for one or more minimal distance - Resident assessment protocols
- structured problem oriented framework - Utilization guidelines:
specific in-state manual detailing when and how to use REI
What are some of the benefits of RAI
- who’s response
- What’s more effective what’s more clear
- involvement?
Resident response to individualized care
Staff communication is more effective
Resident and family involvement increases
Documentation become clearer
What is the Institute of health care improvement promoting as a framework for communication between those and health care about a patient
Define ISBAR. /R
ISBAR is the framework promote it for communication between those in healthcare
I-Identity (name and title)
S-situation (what’s happening with the patient, why are you calling)
B-Background (what led up to being in the hospital what has been done and what hasn’t)
A – assessment (you’re understanding of the problem)
R-recommendation (what would you do to correct the problem)
R-Riesbeck (restate orders if given)


What are the types of reporting that can be done
- changing
- phone
- transfer and what
- reports to who
- mistake
Change of shift reporting “ Handoff”
Telephone
Transfer and discharge reports: -summarization of condition and what was done
Reports to family members and significant others:
-keep informed for rapport
Incident report “ variance report”
-document issues
• ADR, falls, violence the nurse
When you’re giving the change of shift
“ Handoff” Report what do you want to ensure
Basic appraisal orders abnormal unfilled questions transfer and discharge
Basic identifying information of each patient
Clinical appraisal of health status
-how patient is doing
Current orders
-new or discontinued
Abnormal occurrences during shift
Any unfilled orders that need to be continued
Family, patient questions
Report on transfers and discharges
-that may happen within new shift
How do you wanna start a telephone order
How and what do you wanna report during the telephone order
What are two vital things you want to give in the telephone order
What should you have at hand and make responses to
As far as the call would you wanna communicate about the call
Start a telephone order by identifying yourself and the patient, relationship to patient
Report concisely/accurately the change in patient’s condition that is of concern and what has already been done
Report current vitals and manifestation
Have patient record on hand to make knowledgeable responses to physician inquiries
- ***Of call:
- Record time and date
- what was communicated
- physicians response!!!
What does it mean to confer
What do you want to do with consultations and referrals
What are two activities you want to document
What are other activities you want to document
Confer: to consult with someone to exchange ideas or seek information, advice, instructions
Document consultations and referrals
Document nursing/interdisciplinary team conferences and nursing care rounds
Other things to document:
- purposeful rounding,
- EBP interventions
What are the eight behaviors of purposeful rounding
(what do you do when leaving room)
-keywords
accomplish
address the five what
address additional
what what kind of assessment do you want to do
what is the number one question to ask on your way out
what you wanna tell your patient
ultimately what do you do after any interventions
- Use opening keywords
- C-I-CARE with presence
2. Accomplish scheduled tasks
- Address the P’s
- pain, potty(personal needs), position, fall prevention - Additional personal needs, questions
- Do environmental assessment
- “ pump” and hazards - Ask “ is there anything else I can do for you I have time”
- Tell the patient you will be back
- Document rounding
