documentation Flashcards
the client health record
-written or electronic account of patient care
-confidential, permanent, legal record
-communication
-helpful to retrieve information and trend data
-tracks patient outcomes
-assists regulatory agencies in tracking compliance
-used for reimbursement
-used to demonstrate quality care for accreditation process
what to document
-assessment and history
-medication administration
-plan of care
-interventions
-change in patient status
-communication with other staff and providers
-teaching
-essentially EVERYTHING
-if it isnt documented, then it didnt happen
DO guidelines for documentation
-document the time of an event
-include data and time stamp
-include signature with full name and role
-write legibly in black ink
-stay objective
-document all pertinent information and facts
-use military time
DONT guidelines for documentation
-DONT document in future tense
-DONT document opinions
-DONT use general empty phrases
-DONT use jargon or abbreviations
The EHR and HIPAA
-ensure security of your log in password
-dont walk away from an open log in, shield screen
-dont print or make copies of written or EHR records
-only access the client’s chart on a need to know basis
-dont include patient identifiers on concept maps or any notes you take
paper EHR and HIPAA
-shred any papers in the healthcare setting that are no longer being used that contain patient identifiers
-faxing: always use cover page, verify correct fax number of recipient, ensure fax machine is designated to transmit protected health information
documentation formats
-flowsheets
-narrative
-charting by exception (CBE)
flowsheet format
graphic records with charts, boxes, drop downs.
-vital signs
-assessment
-daily care
narrative format
paragraph, story like
-progress notes
-event occurrences
-change in patient status
charting by exception (CBE) format
primarily used with assessments. organization defines what is considered within normal limits (WNL). RN documents only findings that are not WNL
documentation frameworks
-PIE nursing specific
-SOAP used by multiple disciplines
-SBAR
PIE
nursing specific.
Problem
Intervention
Evaluation
SOAP
used by multiple disciplines.
Subjective
Objective
Assessment
Plan
SBAR
Situation
Background
Assessment
Response
informatics
the use of information and technology to communicate, manage knowledge, mitigate error, and support decision making
