Ch 26: Documentation Flashcards
What does HIPPA stand for?
Health Insurance Portability and Accountability Act
Who specifies the guidlines for documentation?
The Joint Commission
How may handoff reports be given?
- Face to face
- In writing
- Telephone
- Audio recording
When are hand-off reports given?
- Change of shift
- Transfer of patient
Who gets the change of shift report and what does it include?
- All nurses on next shift
- Includes
- Condition
- Required care
- Treatments
- Medications
- Any recent or anticipated changes
When is a Transfer Report given?
- Given whenever the patient is transferred to other health care unit such as:
- Nursing unit to nursing unit transfer
- Nursing unit to diagnostic area
- Special settings (OR, ED)
- Discharge and interfacility transfer
The nurse receiving a telephone report should document
- the date and time,
- the name of the person giving the information,
- subject of the information received
- Sign the notation.
Telephone reports usually include
- the client’s name
- medical diagnosis
- changes in nursing assessment
- vital signs
- significant lab data
- related nursing interventions
Define an Incident (Occurrence) Report
A report that documents any event that is not consistent with the routine operation of a health care unit or routine care of a patient
What are some examples of things that would require an Incident Report?
- Patient falls
- Needlestick injuries
- A visitor having symptoms of illness.
- Medication administration errors
- Accidental omission of ordered therapies and
- Circumstances that lead to injury or a risk for patient injury
What should be included in an Incident Report?
- an objective description of what happened,
- what you observed
- the follow up actions taken
Does the Nurse need to notify the HCP when an insident happens?
Yep
Are incident reports included in the pt record?
Nope
They are for internal QC
What is the difference between a TO and a VO?
- TO is a Telephone Order
- VO is a verbal In Person order
- Both are oral reports
What is the documentation responsibility of an HCP regarding TOs and VOs?
Sign the chart with time set by hospital policy
What is SOAP Charting?
- A charting format that includes the following data:
- Subjective
- Objective
- Assessment
- Plan
What is PIE charting?
- A charting format that includes the following data:
- Problem
- Intervention
- Evaluation
What is SOAPIE Charting?
A combination of Soap and Pie charting
What format is used for Focus charting?
DAR
- Data
- Action
- Response
What is CBE charting?
- Charting by Exception
- Only chart when something goes wrong
- Bad and shouldn’t be used as it assumes that all else is as it should be if it wasn’t reported on.
What should we keep in mind regarding IV’s at discharge?
Make sure that fucker is out!
What is the summary of discharge that should be communicated to the pt?
- Use clear, concise description in pt’s language
- Provide care instruction w/ printed documentation and teachback
- ID precautions of self-care and meds
- Review signs/symptoms/complications that need to be reported to HCP
- Give contact info for relevant HCPs and community resources
- Review follow up and continuous treatment
- List time of discharge, mode of xportation and who accompanied client
What does SBAR stand for?
- Situation
- Background
- Assessment
- Recommendation
What does the “I” in ISBAR stand for?
Introduction/Identify self
