Chapter 5-Information Technology Flashcards

1
Q

Elements of documentation

A

Factual: can be subjective and objective.

Accurate and concise: document facts and information precisely without any interpretations.

Complete and current: document information that is comprehensive and timely. Never pre-chart.

Organized: communicate information and a logical sequence.

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2
Q

Legal guidelines

A

Day in time, legible, non-erasable black ink, no blank spaces.

Don’t use correction fluid, erase, scratch out, or black and out errors. Follow facility procedure for corrections.

Sign all documentation with name and title.

Documentation should be factual not personal opinions or criticism.

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3
Q

Documentation formats

A

Flow charts: shows trends

Narrative documentation: records info as sequence of events

Charting by exception: documents any deviations from the norm

Problem oriented medical records: organized by problem or diagnosis. Examples: SOAP, PIE, DAR.

Electronic health records: replacing manual formats

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4
Q

Reporting formats

A

Change of shift report

Telephone reports (common with transfers)

Telephone or verbal prescriptions

Transfer or handoff reports

Incident reports (unusual occurrences)

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5
Q

Telephone prescriptions

A
  1. Have a second nurse listen to the prescription
  2. Repeat it back making sure to include the medication‘s name, dosage, time, route.
  3. Question anything that seems inappropriate
  4. Make sure provider signs the prescription in person within 24 hours
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6
Q

Incident reports

A

Do not put into a clients chart

Examples of occurrences that require an incident report are medication errors, falls, omission of prescription, and needle sticks.

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7
Q

Information security (Privacy Rule)

Promotes the use of standard methods of maintaining the privacy of protected health information (PHI) among health care agencies.

*part of HIPAA

A
  • only team members directly responsible for clients care accessing record
  • clients have the right to obtain a copy of their medical record
  • nurses cannot photocopy any part of a medical record except for documents between facilities and providers
  • Medical records must be kept in a secure area
  • Electronic records are password-protected
  • nurses must not disclose clients info to unauthorized individuals or family members (many hospitals use a code system)
  • Communication about a client should only take place in private settings where people can’t overhear
  • Follow policies and procedures to monitor staff adherence, protocols, computer privacy, data safety
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8
Q

Information security protocols

A

Log off from computer before leaving the workstation

Never share user ID or password

Never leave a medical record or other printed PHI where others can access it

Shred any printed or written client info after use.

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9
Q

SOAP

A

S: subjective data
O: Objective data
A: assessment
P: plan

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10
Q

PIE

A

P: problem
I: intervention
E: evaluation

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11
Q

DAR

A

D: data
A: action
R: response

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