Ch 19: Documenting and reporting Flashcards

1
Q

What is the biggest no no in regards to the active documenting

A

NEVER Document before doing

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2
Q

What does communication enable personnel to do and avoid

How do nurses communicate

A

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

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3
Q

What are some of the purposes of patient records

A
***Communication #1
diagnostic and therapeutic orders
 care planning “ activities”
quality process and performance improvement 
research, decision analysis 
education 
credentialing 
reimbursement 
legal and historical documentation
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4
Q

If it wasn’t documented it wasn’t what

if you don’t document what do you not get what is not given

A

If it wasn’t documented it wasn’t done

If you don’t document you don’t:

  • get reimbursement
  • you don’t give care
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5
Q

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

A

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

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6
Q

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

A

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

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7
Q

 what are elements of documentation

  • content type
  • timing (not what)
  • to policy
  •  ()what must you do to all of your documentation
  • Private
A

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
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8
Q

 What information is confidential give a few examples

Give a few examples of breach of confidentiality

A

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

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9
Q

What kind of standard does HIPAA set in for for what

Give the name for HIPPA

A

HIPPA sets national center for security of electronic protected health information

HIPAA = health insurance portability and accountability act

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10
Q

What patient rights do patients have according to HIPAA

Info in record
modify
List of
 request
Receive
A

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

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11
Q

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

A

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

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12
Q

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

A

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

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13
Q

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

A

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

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14
Q

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

A
  • 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

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15
Q

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



A

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

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16
Q
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
A

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 



17
Q

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

A

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

18
Q

What are a few things and nurse can do in an EHR

A
  • use tools /admin tools
  • develop care plan
  • add to documentation
  • review list of treatment, protocols, meds
  • immediately document care
  • provide higher quality safer care
19
Q

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

A

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:

  1. Standalone personal house record
    - patient fills in own info
    - the info then stored on patient’s computer or Internet
  2. Tethered/connected personal health record
    - EHR
    - linked to specific healthcare organization/information system
20
Q

 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
A

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
21
Q

Describe the methods of documentation

Source orientant
Problem oriented
PIE charting
Focus charting
 Chart by exception
Case management model
 EHR
A

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

22
Q

Define progressive note

Defined the narrative note

A

progress note:
-informs caregiver about patient progress

Narrative note:
-written to routine care, normal findings, patient problems

23
Q

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
A

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

24
Q

Describe a few formats for nursing documentation

Initial nursing assessment
care plan
critical collaborative pathway
progress notes

A

Initial nursing assessment:
-nursing history + physical assessment

Care plan “ patient care summary”
-common problem + diagnosis

Critical collaborative pathways
-detail standardize care plan

Progress notes

25
Q

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

A

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

26
Q

What kind of documentation is a flow sheet

What are the different types of flow sheets:

A

Flowsheets: routine care

Graphic records: vitals
24 hour fluid balance record
MAR
24 hour patient care record
Acuity record
27
Q

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

A

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

28
Q

What does the RAI (resident assessment tool) help us know

What are the four basic components of RAI (resident assessment tool)

A

The RAI Helps us know if the patient belongs in a nursing home

  1. minimum data set
    - gives screening, clinical, functional status
  2. Triggers:
    - specific resident response for one or more minimal distance
  3. Resident assessment protocols
    - structured problem oriented framework
  4. Utilization guidelines:
    specific in-state manual detailing when and how to use REI
29
Q

What are some of the benefits of RAI

  • who’s response
  • What’s more effective what’s more clear
  • involvement?
A

Resident response to individualized care

Staff communication is more effective

Resident and family involvement increases

Documentation become clearer

30
Q

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

A

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)



31
Q

What are the types of reporting that can be done

  • changing
  • phone
  • transfer and what
  • reports to who
  • mistake
A

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

32
Q

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
A

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

33
Q

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

A

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!!!
34
Q

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

A

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
35
Q

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

A
  1. Use opening keywords
    - C-I-CARE with presence

2. Accomplish scheduled tasks

  1. Address the P’s
    - pain, potty(personal needs), position, fall prevention
  2. Additional personal needs, questions
  3. Do environmental assessment
    - “ pump” and hazards
  4. Ask “ is there anything else I can do for you I have time”
  5. Tell the patient you will be back
  6. Document rounding