Documentation Flashcards
Documentation systems allow members of the healthcare care team to
Efficiently document and retrieve clinical data, track patient outcomes, and facilitate continuity of care
Regulators of documentation
The joint commission, legal and legislative bodies, Centers for Medicare Services (CMS), insurance companies, quality assurance departments
Centers for Medicare Services (CMS) is responsible for
Reimbursement
Purposes of the health care record
Interprofessional communication, legal record, financial billing and reimbursement, auditing/monitoring/evaluation of care, education and research
What is the difference between an EHR and EMR?
EMR is the actual application (Ex: CERNER, EPIC), while EHR is WITHIN the EMR (patient health records)
Nurses are legally and ethically obligated to keep all patient information __________
Confidential
Patient status can only be discussed with
Members of the health care team
T or F: Patient data can be used for research or continuing education
True, but permission is needed
Information regarding a patient’s health status may not be releases to non-health care tram members because
Legal and ethical obligations require health care providers to keep information strictly confidential unless express written consent is given by the patient
Public health information (PHI) that can be given
Billing information
Examples of physical security measures for privacy and confidentiality
Placing computers or file servers in restricted areas, using privacy filters for computer screens visible to visitors or others without access
Guidelines for quality documentation
Factual, accurate and authenticated, current, organized, complete and timely, clear and concise
Documentation subjective data
Record patient’s statement word for word in quotation marks
A nurse has just admitted a patient with a medical Dx of CHF. When completing admission paperwork, the nurse needs to record
Objective data observed
Methods of documentation
Flow sheets, progress notes, charting by exception, SBAR, DAR
DAR method of documentation
Data (objective/subjective), Action (interventions), Response (evaluation)
SBAR method of documentation
Situation, background, assessment, recommendation
Method of documentation characterized by only charting abnormal data
Charting by exception
A nurse records that the patient stated his abdominal pain is worse now than last night. This is an example of what method of documentation?
Narrative charting
PIE method of documentation
Problem, intervention, evaluation
SOAP method of documentation
Subjective, objective, assessment, plan
Common record keeping forms within the EHR
Admission nursing history form, patient care summary, care plans, discharge summary forms
T or F: the nurse should document every phone call made to a health care provider
True
The use of verbal orders (VO) is discouraged except in
Urgent or emergent situations
Any event that is not consistent with the routine, expected care of a patient or standard procedures in place on a health care unit or within an agency
Incident or occurrence
A classification used to compare one or more patients to another group of patients
Acuity level
Nurses use _____ ratings to determine hours of care and number of staff required for a given group of patients every shift or every 24 hours
Acuity
Acuity rating systems are based on
Type and number of nursing interventions required by a patient over a 24 hour period
Severity of care
Acuity (Ex: ICU has higher acuity care compared to med-surg units)
What is the purpose of an incident report?
Aid in the hospital’s quality improvement program
_____ _________ incorporates an interprofessional approach to delivery and documentation of patient care
Case management
Interprofessional care plans that identify patient problems, key interventions, and expected outcomes within an established time frame
Critical pathways
Unexpected outcomes, unmet goals, and interventions not specified within a critical pathway
Variances
