chapter 26: informatics and documentation Flashcards

1
Q

documentation

A
  • vital aspect of nursing
  • must document all care provided

nursing documentation systems

  • reflect currect standards of nursing practice and minimize the risk of errors
  • flexible to allow members of the health care team to efficiently document and retrieve clinical data, track pt. outcomes, ad facilitate continuity of care
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2
Q

purpose of health care record

A
  • interprofessional communication
  • legal record of care provided
  • justification for financial billing and reimbursement of care
  • auditing, monitoring, evaluation of care
  • education and research
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3
Q

interprofessional communication within the medical record

A
  • quality of pt. care depends on your ability to communicate with other members of team
  • when a plan is not communicated to all members of the health care team, care becomes fragmented, tasks are repeated, and delays or ommissions in care often occur
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4
Q

communication within the medical record

A

legal documentation
- accuracy is one of the best defenses for legal claims

reimbursements
- clarifies treatment rendered

auditing and monitoring
- improved quality of care

education
- helps anticipate care needed for the pt.

research

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5
Q

what did HITECH establish?

A

provisions to promote the meaningful use o health info technology to improve the quality and value of health care

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6
Q

what will implementing EHR across the health care system do

A

decrease costs and improve the quality of pt. care

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7
Q

EHR

A

attributes, components and advantages

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8
Q

legal risk of electronic documentation

A
  • combination of logical and physical restrictions to protect info
  • computers in restricted areas
  • privacy filters
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9
Q

disposing of info

A
  • safeguard any info that is printed
  • destroy when no longer needed
  • de-identify all pt. data
  • special considerations for faxing
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10
Q

guidelines for quality documentation

A
factual 
accurate
current
organized 
complete
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11
Q

methods of documentation

A

flow charts
progress notes
charting by exception

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12
Q

record-keeping forms within the ehr

A
  • admission nursing history form
  • pt. care summary
  • care plans
  • discharge summary forms
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13
Q

documentation communication with providers and unique events

A
  • telephone calls made to a provider: document every phone call you to make to the health care provider
  • telephone and verbal orders: use of VOs is discouraged except in urgent or emergent situations
  • incidence or occurrence reports: not consistent with the routine, expected care of a pt. or the standard procedures in place on a health care unit within an agency
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14
Q

acuity rating systems

A
  • determine the hours of care and number of staff required for a given of pt. every shift or every 24 ours
  • based on type and number of nursing interventions required by a pt. over 24-hr period
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15
Q

acuity level

A

the classification used to compare one or more pt to another group of pt.

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16
Q

documentation in the long term health care setting

A
  • documentation is governed by individual state regulation, tjc and cms
  • CMS: mandates use of the RAI, including the MDS and CAA
17
Q

documentation in the home health care setting

A
  • medicare has specific guidelines to establish eligibility for home care reimbursements
  • documentation is the quality control and the justification for reimbursement
  • two different data sets set to document clinical assessments and care provided
    - OASIS
    - Omaha system
18
Q

case management

A

incorporates an interprofessional approach to delivery and documentation of pt. care

19
Q

critical pathways

A

interprofessional care plans that identify pt problems, key interventions, and expected outcomes within an established time frame

20
Q

variances

A

unexpected outcomes, unmet goals, and interventions not specified within a critical pathway

21
Q

informatics and information management in health care

A
  • health care info system
  • clinical information system
  • nursing clinical info systems
  • clinical decision support system
22
Q

nursing informatics

A

integrates nursing science, computer science, and information science to manage and communicate data, info, knowledge, and wisdom in nursing and informatics practice