Chapter 10: documentation Flashcards
what is a healthcare documentation?
any written or electronically generated information about a patient
what does the documentation do?
- describes the patient
- Describes the patient’s healthcare
- describes care and services provided
- includes dates of care
standards should agree with the
joint commission standards
what is a medical record…
The medical record is the legal documentation of care provided to a patient.
EMR
EMR (electronic medical record) = a record of one episode of care
EHR =
longitudinal record of health
Nursing Documentation
hould be clear, concise, complete, objective, factual, nonjudgmental; should have proper spelling and grammar; should be recorded ASAP in actual order that events occurred and contain date, time, and signature
What are the 5 aspects of documentation
- Nursing assessment
- Care plan
- Interventions
- Patient’s response to care
- assessment of patients ability to manage
avoid using abbreviations that may be misunderstood. True or False
True
what are the two types of documentation formats
- narrative
- problem-oriented medical records (POMR)
narrative
he traditional method
Time-consuming and lengthy
POMR
Provides a framework for documentation Database Problem list Care plan Progress notes Charting for entire team in same section of record
what are the 5 specific POMR documentation formats?
PIE
Problem, intervention, evaluation
APIE
Assessment, problem, intervention, evaluation
SOAP
Subjective, objective, assessment, plan
SOAPIE, SOAPIER
Subjective, objective, assessment, plan, intervention, evaluation, (revision)
Focus charting (DAR) Data, action, response
charting by exception records what type of data
Records only abnormal or significant data
Right to privacy =
the right to be free from intrusion or disturbance in private life
(HIPAA) stands for
Health Insurance Portability and Accountability Act
The real-time process of passing patient-specific information from one caregiver to another or among interdisciplinary team members to ensure continuity of care and patient safety is often called a
handoff
A sentinel event is an
unexpected occurrence involving death or serious physical or psychological injury or the risk of injury.
what does SBAR stand for
Situation
Background
Assessment
Recommendation
define Situation
What is happening at the current time?
define Background
What are the circumstances leading up to this situation?
define Assessment
What does the nurse think the problem is?
define Recommendation
What should we do to correct the problem?
Antic model
Administrative data (Name, record number, location)
New clinical information to be updated
(Real-time information )
Tasks to be performed (Must be clearly explained)
Illness severity
(Must be communicated)
Contingency
(Plans for change in clinical status)
Incident Reports
When an unusual and unexpected event involving a patient, visitor, or staff member occurs, an incident report is completed.