Documentation Flashcards
Define documentation?
Written or typed legal record of all pertinent interactions with the patient
What are incidental disclosures of PHI?
Incidental disclosure of patient health information is defined as a secondary disclosure that cannot reasonably be prevented, is limited in nature, and occurs as a by product of an otherwise permitted use or disclosure of PHI
What are some examples of permitted incidental disclosures?
Use of a sign in sheet
The possibility of a confidential conversation being overheard- provided that the surroundings are appropriate for a confidential conversation and voice are kept down
Placing patient charts outside exam rooms
Use of white boards
Calling out names in the waiting room
Leaving appointments reminder voicemails
What are some challenges in electronic health records?
Threat in privacy
Training
More complex than paper
Potential impact to time with patient
Lack of standardization
Lack of flexibility of charting style
Who looks at medical records?
Nurses
Doctors
Respiratory therapist
Physical/speech/occupational therapy
Patient care tech
Accounts/billings
Lawyers/judges/jury
Members of public
Expert witnesses
Insurance
What are some mistakes in documentation?
Incomplete or blank spaces
Unsigned
Contradictory information
Changes in the record - not identifying who performed the change and what was changed
What does AIRA stand for?
Assessment
Intervention
Response
Action
What does DARA stand for?
Date
Action
Response
Action
What is a good transitory documentation?
White boards
What should a transitory white board include?
Date
Nurse
Tech
Doctors
Patient preferred name
Patient goals
Pain medication time given
Pain scale
Diet
Define report
To give an account of something that has been seen, heard, done, or considered. Reporting is the oral, written, or computer-based communication of patient data to others.
Types of report?
Incidence / variance
Shift
Bedside
Interdisciplinary
What is I- SBAR- R
Identify- who are you, where you from (hospital, unit), patient name, age, gender
Situation- what is the problem/ reason for contact
Background- what is the pertinent background?
Assessment- what is your assessment of the patient and situation?
Recommendation- what do you think should be done
Read back- any orders received
