Documentation Flashcards
Accurate
Ensure all recorded information is factual, free of errors, and reflects the patient’s condition, treatments, and responses accurately.
Complete
Include all necessary details such as assessments, interventions, patient responses, and any changes in condition to provide a full picture of care.
Concise
Be clear and to the point while including all essential details. Avoid unnecessary repetition or irrelevant information.
Follow Hospital Policy
Adhere to institutional documentation guidelines and standards, including charting methods, timing, and authorized personnel.
Legally Prudent
Ensure documentation is legally sound by avoiding subjective language, ensuring timely entries, and maintaining proper formatting.
Confidential
Protect patient information in compliance with HIPAA (or applicable privacy laws), ensuring that records are only accessed and shared as necessary for patient care.
All information about patients written on paper,
spoken aloud, saved on computer.
–Name, address, phone, fax, social security
–Reason the person is sick
–Treatments patient receives
–Information about past health conditions
What are key ways to prevent breaches in patient confidentiality?
1️⃣ Follow facility policies on patient data protection.
—Hospitals and clinics have strict policies to prevent unauthorized access.
—Policies cover who can access, share, and discuss patient information.
—Violations can result in legal consequences or termination.
2️⃣ Be mindful of social networking and avoid sharing patient details online.
—Posting about patient cases, even without names, can be a HIPAA violation.
—Sharing photos, videos, or workplace details may expose private information.
—Always keep work-related discussions off social media
3️⃣ Review guidelines from textbooks and HIPAA regulations.
—Textbooks and HIPAA guidelines provide up-to-date best practices.
—Learning from real-world case studies helps avoid common mistakes.
—Understanding legal consequences encourages caution and accountability.
Purposes of Patient Records.
—-Communication with other healthcare professionals
—-Record of diagnostic and therapeutic orders
—-Care planning
—-Quality of care reviewing
—-Research
—-Decision analysis
—-Education
—-Legal and historical documentation
—-Reimbursement
Electronic Health Records (EHR)
✅ Real-Time Updates: Medical team can add info STAT for immediate access.
📜 Comprehensive Records: Stores medical history, lab results, medications, and doctor’s notes.
✍️ Legible & Accurate: Eliminates handwritten errors and ensures legal documentation.
🔒 Secure & Accessible: Doctors can securely access records from hospital, home, or office.
💰 Efficient Billing: Automates insurance claims, reduces billing errors, and speeds up reimbursement.
🔄 Prevents Duplication: Ensures all providers see the same updated records, avoiding redundant tests.
✅ Future of Healthcare: EHRs are the cornerstone of modern health information systems.
⏳ Real-Time Access: Provides instant patient data for timely and effective care.
⚕️ Improves Patient Safety: Reduces errors and enhances decision-making.
🕒 Saves Time: Eliminates delays in retrieving lab results or therapy schedules.
📊 Enhances Care Quality: Ensures providers have accurate, up-to-date patient records.
Pathways (Standardized Plan of Care)
—Defines expected outcomes and approximate length of stay.
—Provides a structured care plan for patient management.
Problem-Oriented Medical Record (POMR)
—Organized around patient problems for a structured approach.
—All healthcare professionals record on the same form.
Uses SOAP format (Subjective, Objective, Assessment, Plan) for progress notes.
—Includes flow sheets for tracking vital signs, input/output, etc.
—-Medication Administration Record (MAR) tracks prescribed medications.
Formats for Nursing Documentation
📋 Initial Nursing Assessment: Admission documentation of patient condition.
📝 Care Plan: Outlines nursing interventions and expected outcomes.
📑 Patient Care Summary: Snapshot of patient status and treatment plan.
👩⚕️ Case Managers (RNs): Use critical/collaborative pathways for patient care coordination.
📖 Progress Notes: Ongoing updates on patient status and care.
📊 Flow Charts: Tracks vitals, input/output, wound care, etc.
💊 Medication Administration Records (MARs): Documents prescribed medications.
⚖️ Acuity Records: Measures patient care needs and nursing workload.
🏠 Discharge Summary: Includes home care, SNF, rehab, hospice, or transfer details.
📝 Bedside Shift Report Checklist: Ensures smooth nurse-to-nurse handoff.
📞 Telephone/Telemedicine Reports: Used for critical updates and televideo assessments.
Importance of Patient Information Management
✅ Fundamental Responsibility: Nurses and healthcare providers must collect, organize, and communicate patient data.
📊 Informed Decision-Making: Real-time patient information supports evidence-based care.
⏳ Timely & Effective Care: Access to updated data ensures prompt clinical decisions.
📂 Multiple Data Sources: Combines lab results, assessments, medication records, and progress notes.
⚕️ Improves Patient Safety: Reduces errors and enhances coordination among healthcare teams.
Benefits of Nursing Informatics
✅ Increased Accuracy & Completeness: Ensures precise and thorough nursing documentation.
📈 Improved Workflow: Eliminates redundant documentation, reducing workload.
🤖 Automation of Data Collection: Captures and reuses nursing data efficiently.
📊 Facilitates Clinical Data Analysis: Helps in evidence-based decision-making and quality improvement.
Communication using SBAR
✅ Structured Communication: Organizes patient information for clarity and efficiency.
📋 S – Situation: State the patient’s issue or concern clearly.
“Dr. Smith, this is Nurse Jane from the ICU. I’m calling about Mr. Johnson in Room 305. His blood pressure has dropped to 85/50, and he is showing signs of confusion.”
📜 B – Background: Provide relevant medical history and context.
“Mr. Johnson was admitted for sepsis and has been on IV antibiotics. His baseline BP is typically 120/80. He received 500 mL of IV fluids an hour ago.”
🩺 A – Assessment: Share current observations, vitals, and clinical concerns.
“He appears pale, lethargic, and his heart rate has increased to 120 bpm. I suspect he is not responding well to fluids and may need further intervention.”
📢 R – Recommendation: Suggest next steps or required interventions.
“I suggest increasing IV fluids and considering vasopressor support. Would you like me to start another bolus and prepare for possible ICU transfer?”
⚠️ Challenge: Used variably, especially in critical interdisciplinary events.
Nursing Informatics – Key Information.
📚 Standard Terminologies:
Know the terminology used in electronic records drop-down menus to ensure accurate documentation.
🔒 Security & Privacy of Electronic Data:
Keep patient information confidential.
Log out or close the computer when stepping away.
Follow hospital policy when sharing patient information (phone, visitor, voicemail).
🛡 Strong Passwords:
Example: Jx$7kP!q9B (Use a mix of uppercase, lowercase, numbers, and special characters).
Avoid personal info like birthdays or names.
🌐 Patient Portals:
Web-based tool for patient and healthcare team access to current health information.
Helps engage patients in their care.
Appropriate and “Do Not Use” Abbreviations in Nursing Documentation
❌ U (unit) → Mistaken for “0” or “4” → Use “unit” instead.
❌ IU (international unit) → Mistaken for “IV” or “10” → Use “international unit”.
❌ QD (daily) or QOD (every other day) → Mistaken for each other → Write “daily” or “every other day”.
❌ Trailing zero (X.0 mg) & Lack of leading zero (.X mg) → Decimal errors → Write “X mg” or “0.X mg”.
❌ MS, MSO4, MgSO4 → Confused for morphine sulfate or magnesium sulfate → Write full drug name.
