Documentation Flashcards
What are 3 nursing related functions of the patient Health Care Record?
- communication
- assessment
- care planning
What are other functions of the patient health record?
-legal document, quality assurance, reimbursement, research, education
When will insurance not reimburse for patient care?
Any time harm is done to patient by hospital/facility staff/procedure/event
What is unique about CHF and reimbursement?
If return to hospital 30 days after d/c with CHF insurance won’t reimburse
3 potential issues with Electronic Health Record?
HIPAA (secure login)
Implementation is expensive
Training new users takes effort
Important elements of good documentation (5)
-confidential, accurate, concise/complete/ objective, organized and timely
6 types of documentation records
Clinical Pathway Admission Nursing Discharge summary Nursing Progress Note Plan of Care Flow Sheet
What does a Flow Sheet have on it?
Vital signs, assessment, lab data
What does a Plan of Care have on it?
care plan and concept map
What is a clinical pathway documentation?
targeted to medical procedure/predictable condition
What is on a nursing discharge summary?
expectations after d/c, follow up appointment, when to reach out for assistance
What are 4 types of Nursing Progress Note?
- narrative
- SOAP
- PIE
- FOCUS
This kind of note is easiest to learn, allows detailed explanations and is time sequences phrases but it can be difficult to review for details and takes the longest time
Narrative
This kind of note is a progress note for only 1 health problem and isnt used for general charting
SOAP
What does SOAP stand for?
Subjective (what patient expresses), Objective (vital signs, labs), Assessment (conclusion based on S and O), Plan (interventions)
What does PIE stand for?
Problem, Intervention, Evaluation
What kind of note incorporates plan of care into progress note using nursing diagnosis and is not interdisiplinary?
PIE
What kind of note is broadest and focuses on problem area. It is often used for patient education but it not multidisciplinary
FOCUS (DAR)
What does DAR stand for
Data, Action, Response
When can you use Charting by exception?
only for head to toe assessment
What do you do ibn charting by exception?
Chart only what is abnormal
Who can use Charting by exception?
someone proficient in assessment- not a novice
What documentation occurs when there is an error? Where is it located?
incident report , internal- NOT part of patient chart
What does SBAR stand for?
Situation, Background, Assessment, Recommendation
What do you discuss during Situation in SBAR?
- clear brief statement o what is happening in present time
- provide your name, patient name, unit, room number, vitals
What do you discuss during Background in SBAR?
-releveant clinical information related to situation
what are circumstances leading up situation?
-diagnosis, allergies, baseline vitals/assessment, code status, meds, iv, labs, test results
What do you discuss during Assessment in SBAR?
- your assessment of patient
- what do you think the problem is?
- focused subjective and objective assessment
What do you discuss during Recommendation in SBAR?
- actions requested to help situation
- What to do to correct the problem?
- order change/referral, visit by provider
3 types of orders a nurse can receive?
Verbal (emergencies)
Telephone
Written (preferred)
What is most important thing to give during handoff?
Code status
Where do yuo give report to next shift?
Bedside
