chapter 26: informatics and documentation Flashcards
documentation
- 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
purpose of health care record
- interprofessional communication
- legal record of care provided
- justification for financial billing and reimbursement of care
- auditing, monitoring, evaluation of care
- education and research
interprofessional communication within the medical record
- 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
communication within the medical record
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
what did HITECH establish?
provisions to promote the meaningful use o health info technology to improve the quality and value of health care
what will implementing EHR across the health care system do
decrease costs and improve the quality of pt. care
EHR
attributes, components and advantages
legal risk of electronic documentation
- combination of logical and physical restrictions to protect info
- computers in restricted areas
- privacy filters
disposing of info
- safeguard any info that is printed
- destroy when no longer needed
- de-identify all pt. data
- special considerations for faxing
guidelines for quality documentation
factual accurate current organized complete
methods of documentation
flow charts
progress notes
charting by exception
record-keeping forms within the ehr
- admission nursing history form
- pt. care summary
- care plans
- discharge summary forms
documentation communication with providers and unique events
- 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
acuity rating systems
- 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
acuity level
the classification used to compare one or more pt to another group of pt.
documentation in the long term health care setting
- documentation is governed by individual state regulation, tjc and cms
- CMS: mandates use of the RAI, including the MDS and CAA
documentation in the home health care setting
- 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
case management
incorporates an interprofessional approach to delivery and documentation of pt. care
critical pathways
interprofessional care plans that identify pt problems, key interventions, and expected outcomes within an established time frame
variances
unexpected outcomes, unmet goals, and interventions not specified within a critical pathway
informatics and information management in health care
- health care info system
- clinical information system
- nursing clinical info systems
- clinical decision support system
nursing informatics
integrates nursing science, computer science, and information science to manage and communicate data, info, knowledge, and wisdom in nursing and informatics practice
