Documentation 2 Flashcards
Documentation
Written, legal record of all pertinent interventions with the patient
Report
An account of something seen , heard, done. Considered oral, written and computer based
Patient health record
A compilation of a patient’s health information
Defense of the nurse
It is the nurse’s best defense if a patient or patient surrogates alleges nursing negligence
Purpose of patient’s records
Communication
- Diagnostic and therapeutic orders
- Care planning
- Quality process and performance Improvement
- Research; decision analysis
- Education
- Reimbursement
- Legal and historical documentation
Characteristics of Effective Communication
- Consistent
- Complete
- Accurate
- Concise
- Factual
- Organized and timely
- Legally prudent
- Confidential
Elements of Documentation
- Content
- Timing
- Format
- Accountability
- Confidentiality
Elements of Documentation Timing
Use Military Time
- Document in a timely manner
-if you forget to document something, record it as a late entry
- Date and time written entries and indicate the time of pertinent observations and interventions
-Weite progress notes on admission, transfer, discharged, post op
-Document significant data for seriously ill patients before leaving care
The more seriously ill the patient, the greater the need to keep documentation current
Elements of Documentation: Format
-Check the agency’s policy for documentation
-Make sure you have the correct chart before writing
Use Correct grammar and spelling
-Date and time each entry
Record nursing interventions chronologically on consecutive lines
Never skip lines
-Draw a single line through blank spaces
Elements of Documentation Accountability
- Sign your first initial, last name and title to each entry
- Do not sign notes describing interventions not performed by you
- Do not use dittos, erasures, or correcting fluids
- Follow procedure correcting errors
- Identify each page of the record with the patient’s name and identification number
- Ensure that the patient record is complete before sending it to medical records or before the patient is discharged.
Element of Documentation: Confidentiality
- Patients have a moral and legal right to privacy
- Students are also responsible for maintaining confidentiality and privacy
- Actual patient names and other identifiers should not be used in written or oral student reports
What is confidentiality
All informs 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
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Potential Breaches in Patient Confidentiality
- Displaying information on a public screen
- Sending confidential e-mail messages via public networks
- Sharing printers among units with differing functions
- Discarding copies of patient information in trash cans
- Holding conversations that can be overheard
- Faxing confidentiality information to unauthorized persons
- Sending confidential messages overheard on pagers
Patient Rights
Patient have the right to :
- See and copy their health record
- Update their health record
- Get a list of disclosures
- Request a restriction on certain uses or disclosures
- Choose how to receive health information
Policy for receiving verbal orders in an emergency
- Record the orders in patient’s medical record
- Read back the order to verify accuracy
- Date and note the time orders were issued in emergency
- Record verbal order and name of the physician issuing the order, followed by nurse’s name and initials
