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