Chapter 7 Flashcards
*Is a vital aspect of nursing practice.
*Is the key communication strategy to show pertinent patient data, clinical decisions and interventions, and patient responses in a health record.
Documentation
*Health provider’s documentation
-Assessment, Progress notes, lab values, images, medication ordered, etc.
Medical record
-Use in court
-For financial reimbursement
-Quality improvement: check if providers follow stands of care
Permanent & legal documentation
-Precise language
-Use management
-Avoid unnecessary words or assumptions
Accurate
Medical record is the property of the health facility or agency, not of the patient or primary care provider.
Confidential
Documentation. also called ____, is used to track the application of the nursing process.
Charting
Which is organized by “Source” or author of the documentation entry
Source-oriented (narrative) charting
Which focuses on the problems the patient experiences as a result of being ill
Problem- oriented medical record (POMR) charting
Which centers on the patient from a positive perspective
Focus charting
Which focuses on deviations from predefined norms, using preset protocols and standards of care
Charting by exception
Where data are input to the computer
Computer- assisted charting
Which tracks variances from the clinical pathway
Case management system charting
Standard procedures
Protocols
This type of documentation follows the nursing process and uses problem statements/ nursing diagnoses while placing the plan of care within the nurses’ progress notes
PIE Charting: Problem identification, Interventions, and evaluation
____ is a computerized comprehensive record of a patient’s history and care across all facilities and admissions
Electronic health record (EHR)
Provides for efficient workflow because when orders are entered into the computer, they are automatically routed to the appropriate clinical areas for action
Computerized provider order entry (CPOE)
