Ch. 3: Documentation Flashcards
Chart (healthcare record)
A legal record that is used to meet the many demands of the health, accreditation, medical insurance, and legal systems
The process of adding information to the chart
Charting, recording, or documenting
Documenting involves
Recording the interventions carried out to meet the patients needs
In the charting of interventions
Documenting the type of intervention, time care was rendered, and the signature and title of the person providing care is essential
Anything written or printed
Is a record or proof of activities will play a role in this process
Documentation
Is an integral part of the implementation phase of the nursing process and is necessary for the evaluation of patient care and for reimbursement for the cost of care provided
A majority of facilities use
Electronic health record (HER) asp sometimes referred to as electronic medical record (EMR)
Purposes of patient records
Documented communication, permanent record for accountability, legal record of care, teaching, and research and data collection
Medical record facilitates
Accurate communication and continuity of care among all members of the health care team
Proper charting covers
Physical, emotional, psychological, social and spiritual needs
Used by various government and other agencies to evaluate the institution’s
Patient care, to justify cost reimbursement for care provided, and to establish or review accreditation
Auditors
People appointed to examine patient charts and health records to assess quality care
Peer review
An appraisal by professional coworkers of equal status
Peer review appraises the manner in which an individual nurse
Conducts practice, education, or research
Institutions also have specific procedures to provide for
Quality assurance, assessment, and improvement, which is an audit in health care that evaluates services provided and the results achieved compared with accepted standards
Cost reimbursements rates by the government plans are based on the prospective payment system of
Diagnosis-related groups (DRGs; a system that classified patients by age, diagnosis, surgical procedure, and other information with hundreds of different categories to predict the use of hospital resources
Institutions are reimbursed by insurance companies or government programs only for
Documented patient care
Nursing notes
The form on the patient’s chart on which nurses record their observations, the care given, and the patient’s responses, when deciding whether the necessary and ordered care is being given or was given
The patient chart or health record
Is a legal document; can be used in court proceedings
Patient health records are also used for
Teaching
Patient records that involve research and data collection
Have many uses in the health field
The pressure to contain or limit health care costs has made
Data regarding the usual length of hospitalization and the cost of treatment for specific illnesses or surgeries important for governmental and other health insurance providers
Electronic Health Record
Facilitates the delivery of patient care and supports the data analysis necessary for coordinating patient care
EHRs contain information that is
Identical to that found in traditional records but eliminate repetitive entries and allow more freedom of access to the database
EHRs increase
Efficiency, consistency, and accuracy and decrease costs
Benefits of EHR
The ability for all health care providers to view a patient’s records, encouraging increased continuity of care
EHR vs EMR
Exchange of patient data from one facility to another, vs set up to exchange patient data within a facility
Point-of-care (POC)
Bedside systems
POC systems are sometimes housed on wheeled carts referred to as
Computers on wheels or COWs
Some systems automatically retrieve and record information from
electronic devices and simultaneously enter the data in all relevant locations in the record, which cuts down on duplication of effort
The standard phrases indicate information such as
patient health problems, interventions, and outcomes classification system
Assessment Data are entered by selecting from
a list of preformulated choices, which means that the accuracy and pertinence of the data entered depend on the nurse’s familiarity with the language the system uses to name the patient problems
Naming conventions, or
nomenclature (a classified system of technical or scientific names and terminology), must be considered when choosing computer-based documentation
Informatics
the study of information processing
The personal health record (PHR)
is an extension of the EHR that allows patients to input their information into an electronic database
The PHR allows for a more
comprehensive profile of the patient, and points of convention are how the information is going to be stored, who is going to store the information, and what economic costs are involved
PHR applications may be managed by
private vendors, hospital, primary care health care providers, and insurance companies
-these vendors may choose whether to charge a fee for storage of this information
SBAR
situation, background, assessment, and recommendation, is a method of communication among health care workers and a part of documentation
SBAR is considered a safety measure in preventing
errors from poor communication during interactions between health care personnel
SBAR is recognized by
The Joint Commission, as one method of meeting National Patient Safety Goals
The additional “R” in SBAR that may be used, represents
“read back”
SBARR examples
“Hello, Dr. Reads. This is Nurse Schwenk. I am calling you about Mr. Walter’s presdischarge laboratory results.”
“All his laboratory results are within normal range, except for his serum potassium level. It is 3.1”
“When I was speaking with him about his home medications, he said he has not been taking his potassium supplement for about 2 weeks. He says he forgot to refill the potassium but has continued taking his Lasix”
“Could we give him a new prescription for potassium and include this information on his discharge instructions?”
“Let me read that order back to you to make sure I understood you correctly. ‘Prescription for K-tab, 10 mEq, p.o. B.I.D. and include on discharge instructions
The quality and accuracy of the nursing notes have a decisive impact on the
success or failure
The registered nurse (RN)
has primary responsibility for each patient’s initial admission nursing history, physical assessment, and development of the care plan based on the patient problem identified
Charting Rules
meets the standards expected by the individuals and the agencies that use the charts
Legalities of Documentation
document must indicate clearly that individualized, goal-directed nursing care was provided to a patient, the record has to describe exactly what happened to a patient, chart must be updated immediately after providing care
It is the nurse’s responsibility to indicate all
assessments, interventions, patients responses, instructions, and referrals in the medical record
Inappropriate documentation may lead to
nursing malpractice
Examples of inappropriate documentation
not charting the correct time that events occurred or that an event occurred at all, failing to record verbal orders, charting nursing care in advance, and guidelines for documentation to be kept in mind
Common Medical Abbreviations and Terminology
Avoid using abbreviations or terms that are not standard or in question. Use of the complete word is always better if unsure of the proper abbreviation
Methods of Recording
the documentation system selected by a health care facility optimally reflects the philosophy of the facility and the way nursing care is implemented
The traditional (block) chart
is divided into sections or blocks, emphasis is placed on specific sections of information. Typical sections are admission, information, physician’s orders, progress notes, history and physical examination data, nurse’s admission information, care plan and nursing notes, graphics, and laboratory and x-ray examination reports
Narrative charting
recording of patient care in descriptive form, to chart observations, care, and responses
What is narrative charting used for?
Computerized and noncomputerized nurse’s notes.
Includes the data about the basic patient need or problem, whether anyone has been contacted or consulted, care and treatments provided, and the patient’s response to treatment
Narrative charting is documented in
an abbreviated story form
The problem-oriented medical record (POMR)
is organized according to the scientific problem-solving system or method
The principal sections of a POMR
database, problem list, care plan, and progress notes
Database
from the history, physical examination, and the diagnostic tests are used to identify and prioritize the health problems on the master medical and other problem lists
Problem list
active, inactive, potential, and resolved problems serves as the index for chart documentation
Representatives of all the disciplines involved with the patient’s care
develop a care plan with identified patient problems
All health care providers chart on the same progress notes with forms such as
narrative notes, flow sheets, and discharge summaries to document patient progress
SOAPIER
Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision; an acronym for seven different aspects of charting
SOAPE
the briefer adaptation of the charting format for the POMR
The care given or action taken in SOAPE
is included in the notations under planning
The needed plan revisions for SOAPE
are noted in the evaluation section after the response to treatment is recorded
Focus Charting Format
was developed by nurses, a list of patient problems statements is used as an index for nursing documentation; similar to problem list used for the POMR
What type of charting uses the nursing process?
Focus charting
The focus of focus charting format is
a current patient concern or behavior and sometimes a significant change in patient status or behavior or a significant event in the patient’s therapy
DARE
the acronym for four different aspects of charting using the focus format; Data are subjective and objective, Action is a combination of planning and implementation, Response of the patient is the same as evaluation of effectiveness, education or patient teaching.
With notes of a particular focus, not all aspects
of DARE are used
Some facilities require the narrative notes for each shift to include a minimum of
three entries and a flow sheet on which the nurse charts care given
Charting by Exception (CBE)
the nurse charts complete physical assessment, observations, vital signs, intravenous (IV) site and rate, and other pertinent data at the beginning of each shift
In CBE, the only notes the nurse makes are
for additional treatments done or planned treatments withheld, changes in patient condition, and new concerns
With the CBE method of documentation, the nurse uses
more detailed flow sheets, which enhances the focus on existing concerns e.g., PIE format
The PIE format is a
problem-solving approach; similar to the SOAPE format
SOAPE originated from
the medical model
PIE originated from
the nursing process
SOAPE is oriented to the
problems, interventions, and evaluations involved in nursing care, was designed to provide an ongoing plan of nursing care with daily documentation
The care and assessment flow sheets consist of
standardized assessment criteria and interventions
Sometimes the nurse uses a variation of the PIE format that includes
APIE, the assessment data include subjective and objective data (S and O)
It is unnecessary to chart a narrative note
each time a medication has been given
Kardex (or Rand) system
is used by some facilities to consolidate patient orders and care needs in a centralized, concise way; kept at the nursing station for quick reference or is part of the EHR/EMR
Forms vary among institutions based on
information required for care
The nursing care plan
outlines the proposed nursing care based on the nursing assessment and the identified patient problems to provide the continuity of care, is developed to meet the nursing care needs of a patient
Standardized planning care includes
the pertinent patient problems, goals, and plans for care and specific actions for care implementation and evaluation
Incident report examples
if a nurse neglects to give a medication or treatment or gives an incorrect dose of a drug, or any unusual event that happens in a hospital setting
When filling out an incident report, give only
objective, observed information
The nursing records may be consolidated into a system that accommodates a
24-hour period, helps to eliminate unnecessary record-keeping forms
24-hour patient care records often use
flow sheets and checklists, to enhance further efficacy
Acuity charting
uses a score that rates each patient by severity of illness
Discharge planning begins at
admission
Example of a proper incident report
1700 Felt sharp pain in lower back, 8/10, after assisting patient from bed to chair. Gait belt used to assist in patient transfer. Notified employee health department.
A discharge summary should always be a
written document, concise and instructive
What is managed care?
A systematic approach to care that provides a framework for the coordination of medical and nursing interventions
Clinical (critical) pathways
allow staff from all disciplines to develop standardized, integrated care plans for a projected length of stay for patients of a specific case type
Contents of a clinical pathway
care plan, interventions specific for each day of hospitalization, and a documentation tool
What replaces the nursing care plan?
A clinical pathway
What is the method frequently used for clinical pathways?
CBE
Omnibus Budget Reconciliation Act (OBRA) of 1987
instituted significant Medicare and Medicaid requirements for long-term care provision and documentation
Requirements of OBRA are
MDS and regulated standards for resident assessments, individualized care plans, and qualifications for health care providers
Long-term documentation supports a
multidisciplinary approach in the assessment and the planning process
The Office of the National Coordinator for Health Information Technology (ONC), part of the department of Health and Human Services
is working continually on making access to medical records easier and less time consuming for patients, currently focusing on PHR
The Patient Care Partnership
guarantee that medical information is kept private, unless the information is needed in providing care or the patient gives permission for others to see it
HIPAAA
affords certain protections to persons covered by health care plans, including continuity of cover when changing jobs, standards for electronic health care transactions, and primary safeguards for the privacy of individually identifiable patient information
