Chapter 16 Flashcards
Elements of Documentation
- Content
- Timing
- Format
- Accountability
- Confidentiality
Patients have the right to:
- See and copy their health record
- Update their health record
- Get a list of disclosures
- Request a restriction on certain uses or disclosures
- Choose how to receive health information
Policy for Receiving Verbal Orders in an Emergency
- Record the orders in patient’s medical record.
- Read back the order to verify accuracy.
- Date and note the time orders were issued in emergency.
- Record verbal order and name of the physician issuing the order, followed by nurse’s name and initials.
Policy for Physician Review of Verbal Orders
- Review orders for accuracy.
- Sign orders with name, title, and pager number.
- Date and note time orders signed.
Duties of RN Receiving Telephone Orders
- Record the orders in patient’s medical record.
- Read orders back to practitioner to verify accuracy.
- Date and note the time orders were issued.
- Record telephone orders, and full name and title of physician or nurse practitioner who issued orders.
- Sign the orders with name and title
Purposes of Recording Data
- Facilitate patient care
- Serve as a financial and legal record
- Help in clinical research
- Support decision analysis
Standalone personal health records:
Patients fill in information from their own records; the information is stored on patients’ computers or the Internet.
Tethered/connected personal health records:
Linked to a specific health care organization’s electronic health record (EHR) system or to a health plan’s information system.
Methods of Documentation
- Source-oriented records
- Problem-oriented medical records
- PIE charting (problem, intervention, evaluation)
- Focus charting
- Charting by exception
- Case management model
- Computerized documentation/Electronic health records (EHRs)
PIE charting
incorporates the plan of care into progress notes in which problems are identified by number.
source-oriented records
paper format in which each health care group keeps data on its own separate form
Problem-oriented medical record
organized around a patient’s problems rather than around sources of information
-all health care professionals record on the same forms
Focus charting
replaces the problem list with a focus column that incorporates many aspects of a patient and patient care
Charting by exception
shorthand documentation method that makes use of well-defined standards of practice; only significant findings to these standards are documented in narrative notes
Case Management Model
promotes collaboration,communication, and teamwork among caregivers; makes efficient use of time; and increases quality by focusing care on carefully developed outcome.
