Documentation Flashcards
Documentation
written or legal record of all pertinent interactions with the pt
Read-back
the recipient reads back the message as they heard and interpretted it
Narrative notes
- subtype of progress note
- addresses routine care, pt data, and pt problems indentified in care plan
Patient record
complilation of a pts health information
Problem-oriented medical record (POMR)
Records organized around a pts problems rather than the sources of information
Progress notes
Notes written to inform caregivers of the progress a pt is making toward the expected goal
Source-oriented medical record
- paper format in which each health care group (nurse, healthcare provider, x-ray) keeps data on its own separate form
- includes progress notes: narrative notes
- most recent entries are near the front, but data is fragmented since each dicipline maintains its own separate form (makes it difficult to follow a patients problem chronologically)
Health information exchange
secure, electronic sharing of vital medical information among healthcare providers and patients, with the goals of improving the speed, quality, safety, and cost of patient care
Change-of-shift report (Handoffs)
given by primary nurse to the nurse replacing them or from charge nurse to nurse who is continuing care of pt
- can be wriitten, orally or audio/ or videotaped, bedside report
Bedside reports
shift report given at the bedside
Acuity records
- Rank patients high-to-low acuity in relation to patients conditions and need for assistance
- Used to determine staffing requirements
Telehealth
- use of electronic information and communication to provide care to pts.
- Used for: Wellness visits, nutrition counseling, mental health counseling, back pain etc
Remote Monitoring
the use of devices to collect and transmit pt health data form home to a healthcare facility
Mobile care teams
healthcare professionals who travel to provide care to pts in rural or underserved areas.
Incident report
(AKA, Define)
- AKA: variance report
- document unexpected events that result in harm of pt or damage to property
- NEVER GO ON A PATIENTS MEDICAL RECORD
A student nurse, Karen, is tasked with documenting a patient’s vitals and any other observations she makes during their interaction. Karen has a history of being a terrible note-taker and is notorious for using her favorite light green pen. Since she has yet to be diagnosed or medicated for her ADHD, she omits information she deems unworthy and uses her own abbreviations, like ATF (attracted to floor) and TCM (they can’t move), for her immobile, fall-risk patient.
What are some corrections that Karen should make when documenting her future interactions?
Use a darker ink:
- using a darker ink (ex: black, navy) allows the writing to be more legible
Make Notes more legible
- use good handwriting to prevent any errors in note taking
Record objective and subjective date more accurately
- always document information accurately to prevent error
avoid using unnecessary and unapproved abbreviations
- Use abbreviation that are approved and have less error prone
T/F: Students are allowed to take photos of patients or their the clinical setting
False: students should never take photos of any patient or their clinical setting
Josh, a student nurse, has a tendancy to use words such as, good, average, and normal. Why can the use of these words be problematic when documenting?
Words like, good, average, and normal mean different things to different people. When documenting it is important to document measurable, verifiable objective date.
What should be included when documenting an entry?
- Date
- Time
- Name
- Title
T/F: Students should never use thier celphone in the clinical setting
True
T/F: Students are allowed to use the computer in the clinical setting for personal communication
False: studetns should never used the computers in the clinical setting for personal communication
What manner do you record problems?
Sequential Manner
Joe, an RN, was given a quesitonable medical order and/or treatment? What is his best course of action?
Joe should record the date, time, and name of the provider who was notified about the concern as well as their exact response.
If taking verbal orders over the phone, what should you always do?
Have a second nurse listen to the conversation and cosign the note.
How should verbal orders be documented?
- Documented as VO (verbal order)
- include date, time, name and credentials of provider who gave the orders
T/F: Always copy and paste notes in an EHR
False: refrain from copying and pasting notes in an EHR because the data may be outdated/inaccurate.
____ document interventions before carrying them out
NEVER
Compare and Contrast the following documentation:
Flow Charts/Sheets:
Graphic Charts:
Progress Notes: (focus on pt problems)
Care plans:
(What Is It? What Is It Used For? What Type of Records Is It Used In? Types)
Just practice filling out the chart in master notes
Flow Charts/Sheets:
- Fill in the blank sheets
-> Used in: Source-Oriented Medical Records - Used for routine care:
-> respiratory, cardiac, pain, nutrition, activity, hygiene, sleep, teaching
Graphic Charts:
- Used in: Source-Oriented Medical Records
- Shows trends in:
-> V/S, weight, I & O
Progress Notes: (focus on pt problems)
- Notes progress pt is making toward achieving expected outcomes
- Formatted: Narrative Notes, SOAP, PIE
Care plans:
- Assesses pt baseline and notes how pt responds to treatmeant plan
- outlines pt healthcare needs, including SMART goals, nursing interventions, and evaluations
T/F: You should never leave the unit for a break when caring for a seriously ill patient until are significat data is recorded
True
What are the characterisitcs of effective documentation?
- accessible
- accurate
- relevant
- cossitent
- clear
- concise
- complete
- legible/readable
- thoughtful
- timely
- contemporaneous (exisiting in the same time period)
- sequential
- nursing process
- retrieveble on a permaent basis
As Josh is recording and documenting a patients new pressure sore development, he mistakes the left arm for the patients right leg. In order to correct his mistake, Josh uses a sharpie to scribble out his mistake and continues with his documentation?
Did Josh do anything wrong? How can Josh improve?
Instead of blacking out a mistake, Josh should draw a single line through it an label it as either “mistaken entry” “error in charting”.
Josh should rewrite the correct data, an include the date, time, his signature and title.
A patient’s family member calls and asks for updates on their loved one’s condition. How should you respond while maintaining patient confidentiality?
Politely inform them that patient information is confidential and cannot be shared over the phone unless they have proper authorization.
A nurse is charting patient progress using SOAP format. What does SOAP stand for, what type of record is it used in, and how does it differ from PIE charting?
- SOAP: Subjective data, Objective data, Assessment, Plan (+Evaluation). Used in problem-oriented medical records.
- PIE: Problem, Intervention, Evaluation. Unique charting system where care plan is built into the progress notes, eliminating a separate care plan.
When should you document the interactions youve had with your patients?
- As close to the time of assessment
How does Electronic Health Records (EHR) improve nursing documentation and patient care?
EHR reduces medical errors, improves accuracy, eliminates redundant documentation, automates data collection, and improves workflow
Describe the information for the following:
- Electronic Medical Record (EMR)
- Electronic Health Record (EHR)
(Information included, Key differences)
EHR & EMR Include:
- Patient Demographics
- Medical Hx
- Dx
- Rx & Tx plan
- Progress notes
- Lab results
- Imaging results
Key Differences
- EMR: Data is confide to a single facilty or a group of facilities under common ownership
-
EHR: Share data between facilities under different ownership
-> pt decides what portion of their records are shared
What are the benefits of the health information exchange (HIE)?
- Improve speed, quality, safety and cost of pt care
- Efficient use of new technology and health care services
- ⬇ Re-admissions, medication errors, duplicate testing
- Improves diagnoses
What are best measures to take when using an EHR database to ensure patient privacy and security?
- Log off/close computer before leaving work station
- DON’T share user ID or password
- Use strong password
- NEVER create/change/delete if you have no specific authority to do so
- NEVER email pt information unless it is encrypted
What are best measures to take when using a written database to ensure patient privacy and security?
- Never leave PHI (patient health information) where other can get them
- Shred printed/written pt information
Why do hospitals use military time (24-hour clock) instead of the standard 12-hour system?
- prevents errors caused by AM/PM confusion
- ensures accurate time documentation in patient records.
A patient living in Whoknowsit?, New Humphrey, requires frequent check-ups. They aren’t able to make frequent commutes since they live 80 miles away from their primary care doctor. What options/alternatives should their doctor offer to them to accomodate to their needs.
The doctor should offer Telehealth (virtual visits), remote monitoring (wearable health devices), and mobile care team to accomodate their needs.
What are the benefits of telehealth, remote monitoring and mobile care teams?
Patients are able to recieve quality patient care at the comfort of their homes
What are the exceptions where you can release patient health information (PHI) without the consent/authorization of the patient?
Public Health Activities:
- Tracking and notification of DZ outbreaks
- Infection control
- Statistics r/t dangerous problems with drugs or medical equipment
Law Enforcement & Judicial Proceedings:
- crucial to the investigation/prosecution of a crime
- identify victims of crime or disasters
- Reporting incidents of child abuse, neglect or domestic violence
Deceased people:
- Needed by coroners, medical examiners and funeral directors
- Facilitate organ donations
- Given to law enforcement if there is a death of a potential crime
A high school principal contacts the local hosipal about Hubert, a 17 yr old student who appeared weak and glum throughout the school week. Concerned for Huberts’ health, the school administrations wishes to obtain Huberts medical records to see if there is anything they can do to improve Huberts mood.
Is the school administration able to obtain Huberts health records? Why or Why not?
No, the school administration can not have access to a patients health information (PHI) without the consent/authorization from the patient or the patietnts guardian
Mrs. Abby’s mom calls the hospital, frantic with worry. Her 24-year-old daughter, Abby, was recently admitted to the emergency room after collapsing at work. She explains to the nurse that she is her mother and primary caregiver, has always handled her medical decisions, and needs to know her condition immediately.
Is Abby’s mom able to obtain her daughters patient health information? Why or Why not?
No, Abby’s mom could not have access Abbys PHI without Abbys written or verbal consent .
A local health department receives multiple reports of patients presenting with severe flu-like symptoms, high fever, and difficulty breathing. When lab tests confirm that several cases are linked to a new strain of a contagious virus, the hospital immediately reported these cases to the Centers for Disease Control and Prevention (CDC) and the state health agency.
Is the hospital allowed to disclose PHI without the consent/authorization of the patient involved? Why or Why not?
Yes, the hospital is at liberty to disclose PHI without needing patient consent because it is necessary to track the disease outbreak.
A nurse at a nursing home notices that several residents have developed symptoms of a bacterial infection, including vomiting, diarrhea, and fever. Some patients have been hospitalized. To prevent further spread, the hospital and long-term care facility report the outbreak to the local public health office, which then conducts an investigation and enforces safety measures such as quarantine protocols and increased sanitation efforts.
Is the hospital allowed to disclose PHI without the consent/authorization of the patient involved? Why or Why not?
Yes, the hospital can disclose PHI without the consent/authorization of the patient invoved becuase infection control requires timely reporting to prevent further spread.
A hospital notices a sharp increase in patients experiencing severe side effects after receiving a specific brand of insulin. Some patients have dangerously low blood sugar levels despite taking the prescribed dose. Concerned that the medication may be defective, the hospital reports the adverse reactions to the FDA and drug manufacturers for investigation.
Is the hospital allowed to disclose PHI without the consent/authorization of the patient involved? Why or Why not?
Yes, the hospital can disclose PHI without the consent/authorization of the patient invoved because they are required to report statistics related to dangerous problems with drugs or medical equipment.
A man is rushed to the emergency room with a gunshot wound to the chest. When questioned by the doctor, he refuses to say how he was injured and insists it was an accident. However, hospital staff suspect the wound is related to a recent armed robbery reported on the news. The hospital notifies law enforcement, who then arrive to question the patient and collect forensic evidence.
Was the hospital staff allowed to release patient heath information to law enforcment without the consent/authorization? Why or Why not?
Yes, hosiptal staff are allowed to release patient health information if it is crucial to the investigation/prosecution of a crime.
A massive earthquake strikes a metropolitan area, causing widespread destruction and hundreds of injuries. Emergency responders rush survivors to local hospitals, but many arrive unconscious, disoriented, or without identification. A man with severe head trauma is admitted to the ICU, but he is unable to communicate his identity.
As hospitals work to treat victims, the state emergency management agency and law enforcement request patient information from local hospitals to help identify missing persons and notify families. The hospital provides basic demographic details, descriptions, and medical conditions of unidentified patients to aid in victim identification and reunification efforts.
Is the hospital allowed to release the patient health information of the victims of the earthquake without their consent/authorization? Why or Why not?
Yes, hospitals are allowed to release the patient health information of disaster victims to identify victims of crime or disasters
A pediatrician notices unexplained bruises, malnutrition, and signs of emotional distress in a 5-year-old child during a routine checkup. When asked about the injuries, the child nervously says they fell down the stairs, but the explanation does not match the injury pattern. Suspecting child abuse, the doctor reports the case to Child Protective Services (CPS), which then launches an investigation into the parents.
Was the doctor allowed to release the childs health information to Child Protective Services (CPS)? Why of Why not?
Yes, healthcare professionals are required to report incidents of child abuse, neglect and/or doestic violence.
A 52-year-old man is found unresponsive in his home and is pronounced dead on arrival at the hospital. Since the cause of death is unknown, the hospital released medical records and autopsy information to the county medical examiner, who must determine whether the death was due to natural causes, an accident, or foul play. Once the examination is complete, the medical records are also shared with the funeral director to assist with proper handling of the remains and issuance of a death certificate.
Was the hospital allowed to release patient information to the coroner, medical examiner and the funeral director? Why or Why not?
Yes, the coroners and medical examiners needed access to medical records to determine cause of death. The funeral director also needed medical records to prepare the body and issue legal documentation.
A 25-year-old woman suffers a traumatic brain injury in a car accident and is declared brain dead after multiple neurological tests. She is a registered organ donor, so the hospital notifies the local organ procurement organization (OPO). The OPO requests access to her medical history, blood type, and organ function test results to determine whether her organs are viable for transplant and to match them with waiting recipients.
Was the hospital allowed to release patient information to the organ procurement organization (OPO)? Why or Why not?
Yes, the hospital is allowed to release patient information to facilitate organ donations.
A 32-year-old man is brought to the ER with multiple stab wounds. Despite the medical team’s efforts, he succumbs to his injuries. Since the injuries appear to be caused by an assault, hospital staff notify law enforcement, who request the man’s medical records, cause of death, and evidence collected during treatment (such as blood samples or foreign objects). The police use this information to investigate the homicide, identify suspects, and gather forensic evidence for prosecution.
Was the hospitall allowed to release patient information to law enforcement? Why or Why not?
Yes, the hospital is allowed to release patient health information to law enforcement if there is a death of a potential crime
Abby and Karen are in teh hosiptal cafeteria, talking about a patients recent surgery and health complications. A nearby nurse overheard their conversation and was able to recognize the patients name.
What is wrong with interaction between Karen and Abby? What can they do to fix this?
Abby and Karen were discussing confidential patient details in a public space.
Abby and Karen should refrain from discussing patient information in a public space. If discussing a case is necessary, conversations must be done in a private and secure location. They should also not use any information that can be used to identify the patient.
Josh printed out a patient’s test results, but a code blue alarm sounded. Josh dropped everything he as doing to go help in the code blue. A patient found the test results on the ground and started reading and sharing the information.
What mistake did Josh do? How can he fix his mistakes?
Josh left confidential medical records unattened in a public space and put patient information at risk.
Patient records should always to be secured and should never be left unattended.
Karen prints extra copies of a patient’s lab results to help a coworker, but instead of shredding the extra copies, she takes them home by mistake. Later, her roommate finds the papers on the kitchen table.
What did Karen do wrong? What can she do to fix this?
Karen made extra copies and failed to dispose of them properly.
You should only print essential copies and immediately dispose of extras in HIPAA-complaint shredding bin.
________ use a patients ________ when preparing written or oral reports for school
Never; name
what is the only permanent legal document that details the nurses interaction with the patient?
patient record
T/F: Documentation reflects the nursing process and your professional responsibilites
True
patient records include ________ and ________ orders
Dianostic; Therapeutic
T/F: Students should never use any patient information on any social media platforms
True
________ is the primary means of communication when discussing pts among other providers.
patient record
Compare progress notes vs problem-orientated medical records (POMR)
(what does it include?)
Progress notes
- Focus on pt problems
POMR
- defined datebase
- problem list
- care plans
- progress notes
T/F: All patient information is considered private and confidential
T: All patient information is considered private and confidential, whether written, saved on a computer, or spoken aloud
