DOCUMENTATION Flashcards
- is the written, legal record of all pertinent interactions with the patient
DOCUMENTATION
- also known called as recording or charting, is the process of making an entry on a client record
DOCUMENTING
Clinical Record
- also called chart, client record or patient record, is a formal, legal document that provides evidence of a client’s
care. It is a compilation of a patient’s health information. Although health care organizations use different systems and
forms for documentation, all client records have similar information.
CLINICAL RECORD
- is the process of systematic and continuous collection, validation and communication of patient data
ASSESSMENT
- identifying actual or potential health problems that can be prevented or resolved by nursing intervention (North
American Nursing Diagnosis Association = NANDA)
DIAGNOSING
process of formulating patient goal, an expected patient outcome, an expected conclusion to a patient health
problems, or in the event of a wellness diagnosis
PLANNING
- the process of carrying out the plan of action, to promote health, prevent disease and illness, restore health and facilitate coping with altered functioning
IMPLEMENTING
the process of measuring how well the patient has achieved the goals/ outcome specified in the plan of care
Evaluating
- It helps healthcare professionals from different departments who interact with the patient at different times to
communicate with one another. This prevents fragmentation, repetition and delays in client care
COMMUNICATION
- Each health professional uses data from the client’s record to plan care for that client. A primary provider, for
example, may order a specific antibiotic after establishing that the client’s temperature is steadily rising and that
laboratory tests reveal the presence of a certain microorganism. Nurses use baseline and ongoing data to evaluate the
effectiveness of the nursing care plan
PLANNING CLIENT CARE
- An audit is a review of client records for quality-assurance purposes. Charts may be reviewed to evaluate the quality
of care patients have received and the competence of the nurses providing that care. Accrediting agencies may review
client records to determine if a particular health agency is meeting its stated standards
QUALITY REVIEW/ AUDITING HEALTH AGENCIES
- The information contained in a record can be valuable source of data for research. Patient records may be studied by researchers who hope to learn from the study of similar cases how best to recognize or treat identified health problems
RESEARCH
- record review may reveal both underutilized and over utilized services, patients with prolonged stays who require
special assistance, and financial information about which services generate revenue compared with those that cost the institution or agency money
HEALTH CARE ANALYSIS
- healthcare professionals and students reading a patient’s chart can learn a great deal about the clinical manifestations
of particular health problems, effective treatment modalities, and factors that affect patient goal achievement
EDUCATION
- The client’s record is a legal document and is usually admissible in court as evidence. It may be used as evidence in
court proceedings, and therefore play an important role in implicating or absolving health practitioners charged with
improper care. In some jurisdictions, however, the record is considered inadmissible as evidence when the client objects,
because information the client gives to the physician is confidential. - It can also be used in accident or injury claims made by the patient.
LEGAL DOCUMENTATION
