Chapter 26 Flashcards
To eliminate Barriers that could cause delay, health care providers are
1: required to notify patients of their privacy policy
2: make a reasonable effort to obtain written acknowledgement of this notification
Documentation
Anything written or printed which you rely on as a record or proof of patients actions
The joint commission standards of documentation require
That all patients admitted to a facility have an assessment of physical, psychosocial, environmental, self-care, knowledge level and discharge planning needs
Diagnosis-related group
Classification system based on patient’s medical diagnoses and supports reimbursement
Education
Education of a patient is critical. The patient care record tells the nature of their illness and the response to it
Research
Using patient’s records for medical research studies to bring about evidence-based practice
Auditing
Reviews the financial charges and determines the degree to which standards of care are met
Guidelines for quality documentation and reporting
Factual Accurate Complete Current Organized
Problem-oriented medical record
Emphasizes patient problems
Narrative
Story-like format that is repetitious and time consuming
SOAP
Subjective-Objective-assessment-plan
SOAPIE
Subjective- objective-assessment-plan-intervention-evaluation: similar to the nursing process
PIE
Problem-intervention-evaluation: unifies the care plan and progress notes
Focus charting
DAta Action Response: follows nursing process and incorporates all aspects of the nursing process
Electronic health record
Record of patient health information generated whenever they enter a health care delivery setting
Source record
Separate sections for organizing a patient’s chart.
Case management
Incorporates an interdisciplinary approach when documenting.
Critical pathways
Interdisciplinary care plans that include problems, interventions and expected outcomes
Admission nursing history forms
Guides the nurse through a complete assessment to identify relevant problems and diagnoses
Flow sheets
Allows quick and easy entering of assessment data. Help team members to quickly find trends over time.
Kardex
A portable flip notebook. Organizing information for quick access.
Acuity records
Determined by a computer based on the type and number of nursing interactions over 24-hours
Standardized care plans
Established guidelines for who to care for all patients with similar problems.
Discharge summary forms
Plan for home care, support and equipment necessary to leave.
