Chapter 5-Information Technology Flashcards
Elements of documentation
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.
Legal guidelines
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.
Documentation formats
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
Reporting formats
Change of shift report
Telephone reports (common with transfers)
Telephone or verbal prescriptions
Transfer or handoff reports
Incident reports (unusual occurrences)
Telephone prescriptions
- Have a second nurse listen to the prescription
- Repeat it back making sure to include the medication‘s name, dosage, time, route.
- Question anything that seems inappropriate
- Make sure provider signs the prescription in person within 24 hours
Incident reports
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.
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
- 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
Information security protocols
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.
SOAP
S: subjective data
O: Objective data
A: assessment
P: plan
PIE
P: problem
I: intervention
E: evaluation
DAR
D: data
A: action
R: response