Documentation Flashcards
maintaining pt confidentiality on computers (6)
- Do not share personal password
- Never leave the computer unattended after logging in
- Do not leave pt info on screen where others can see
- Shred all unnecessary sheets - cut pt’s ID info off paper if you must take it out of facility
- IT must install firewall
- Follow policy for charting sensitive info
purposes of pt records (8)
- Communication - prevents repetition & delay in care
- Planning care - evaluate plan’s effectiveness
- Auditing health agencies - can be reviewed for quality assurance
- Research - info about populations of pts can help with treatment plans for others
- Education
- Reimbursement - must contain correct DRG (diagnosis related groups)
- Legal documenation - admission in court as evidence unless pt objects
- Health care analysis - ID agency needs - overutilized & underutilized resources
most common type of charting
source oriented records
easily located each discipline’s form
easy to trace info specific to one’s discipline
info about particular problems distributed throughout
source oriented charting
must chart in clear, chronologic, coherent manner
narrative charting
Data arranged according to pt’s problem
encourages collaboration
alerts caregivers to pt needs
caregivers differ in ability to use
takes constant vigilance to maintain updated list
inefficient because assessments/interventions must be repeated
problem oriented medical record
parts of the problem-oriented chart (4)
database
problem list
plan of care
progress notes
SOAPIER documentation
- S - subjective
- O - objective
- A - assessment
- P - plans
- I - interventions
- E - evaluations
- R - revisions
focuses on pt’s strengths
focus charting
DAR
data, action, response
CBE
charting by exception
only charting what is different/problematic/unexpected
eliminates lengthy, repetitive notes
makes pt changes more obvious
risk for negligence
charting by exception
advantages of computer documentation (5)
- Focus on pt outcomes
- Links sources to pt info
- Bedside terminals eliminate paper notes
- Legibility improved
- Improves communication
disadvantages of computer documentation (4)
- Privacy may be infringed
- Tech breakdowns
- Expensive
- Extended training required
Assign a case manager to pt
ensures quality, cost-effective care delivered w/i length of stay
case management model
critical pathways used for…
common diseases
variance
document…
a goal that was not met
- Document actions taken to correct
- Document justification of actions taken
Concise method of organizing & recording data
Cards kept in portable index file or computer
Info quickly accessible
Pertinent info about pt arranged in sections
kardexes
sections in a kardex (6)
- Allergies
- List of meds
- Daily treatment & procedures
- Diagnostic procedures
- Physical needs to be met
- Stated goals
examples of flow sheets
- Graphic record - VS, weight, etc
- I & O record
- MAR - medication administration record
- Skin assessment record
Completed when pt discharged or transferred
discharge/referral summary
components of a d/c and referral summary (8)
- Description of pt physical, emotional, mental status
- Resolved health problems
- Tx to be continued
- Current meds
- Restrictions
- Self-care abilities
- Support networks
- Referral services
administers medicare
Health Care Financing Administration
regulates documentation for long term care
Omnibus Budget Reconciliation Act (OBRA)
long term care documentation
- Minimum Data Set assessment & screening w/i ______ of admission
- Plan of care w/i _____ of admission
- Review & revise plan of care every ______
- Report any change in pt condition to Dr & family w/i _____ & measures taken to change condition
4 days
7 days
3 months
24 hours
there must be an RN in a long term care facility at least ___ hrs per day
8
_______ requires standardized documentation for home health care
Health Care Financing Administration
2 record required for home health care
- Home health certifications & plan of treatment form
- Medical update & pt info form
how to sign documentation
“S. Boyer, SN”
documentation NOs (6)
- chart in advance
- Leave blank space - strike through empty space & sign
- Use vague terms
- Alter record
- Record assumptions
- Include “pt” or pt’s name or include “I did…” (conciseness)
- Ask & respond to questions
- Provide basic IDing info
- ISBAR
change of shift report
used to report to other caregivers about a pt’s situation
ISBAR
rules about telephone/verbal orders (5)
-
Write complete order down
- “T-O” - telephone order; “V-O” - verbal order
- “Dr. XYZ/S. Boyer”
- Read it back to ensure accuracy
- Question any order unusual or contraindicated
- Have PCP verbally validate read-back
- Countersign by PCP in 24hr
- Meeting to discuss potential solutions to pt problems
- Allows each nurse opportunity to offer opinion
- Other providers invited to offer expertise
plan of care conference
- 2+ nurses visit pts at bedside, often with case manager
- Obtain info that will help plan nursing care
- Provide pt opportunity to discuss care
- Use simple terms for pt’s understanding
nursing rounds
Joint Commision requires care plans to include… (5)
- Evidence of client assessment
- Nursing diagnosis
- Nursing interventions
- Client outcome
- Current nursing care plan
RAI and MDS use
screening tool to establish a baseline of new incoming clients into a long-term care facility and additional periodic documentation reviewing and revising the assessment as clients’ needs change
elements of malpractice
(1) a professional duty owed to the patient; (2) breach of such duty; (3) injury caused by the breach; and (4) resulting damages
