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
Policy for physician or a nurse practitioner review of verbal orders
- Review orders for accuracy
- Sign orders with name, title, and pager number
- Date and note time orders signed
Duties of RN reviewing TelephyOrders
- Record the orders in patient’s medical record
- Read orders back to practitioner to verify accuracy
- Date and note the time orders were issued
- Record telephone orders, and full name and title of physiotherapy nurse practitioner who issued orders
- Sign the orders with name and title
Purpose of Recording Data
- Facilitate quality, evidence based patient care
- Serve as a financial and legal record
- Help in clinical research
- support decision analysis
Two types of personal Health Record
Stand-alone personal health records: Patients fill in information from their own records; the information stored on patient’s computers or the internet
- Tethered/ connected personal health records: Linked to a specific health care organization’s electronic health record system or to a health plan’s information system.
Methods of Documentation
- Source-oriented records- each discipline charts separately
- Problem- oriented medical records -identifies pt. Problems. SOAP/ SOAPIE format
- PIE charting - progress notes
- Focus charting
- Charting by exception
- Case management model
- Compterized documentation/ electronic health records
Major Components of problem oriented medical record
- Defined database
- Problem list
- Care plans
- Progress notes
- SOAP format
Format for nursing documentation
-Initial nursing assessment
- Care plan; patient care summary
Critical collaborative pathways
- Progress notes
- Flow sheets and graphic record
- Medication record
-Acuity record
-Discharged and transfer summary
-Long germ care and home care documentation
Types of flow sheets
- Graphic record
- 24 hour fluid balance record
- Medication administration record (MAR)
- 24 hour patient care record
- Acuity records
Four Basic Components of RAI
- Minimum data set
- Triggers
- Resident assessment protocols
- Utilization guidelines
Benefits of RAI
- Residents responds to individualize care
- Staff communication becomes more effective
- Resident and family involvement increases
- Documentation becomes clearer
Hand -off Communication/ ISBARR
- Identity/ Introduction
- Situation
- Background
- Assessment
- Recommendation
- Read back of orders/ response
Telephone / Telemedicine Reports
- identify yourself and the patient, and state your relationship to the patient
- Report concisely and accurately about the patient’s Cindy
- Report the patient’s current vital signs and clinical manifestations
- Have the patient’s record at the hand to make a knowledgeable responses to any physician’s inquiries
- Concisely record time and date of the call
Conferring about care
- Consultant and referrals
- Nursing and interdisciplinary team care conferences
- Nurisng care rounds
- Purposeful rounding
Purposeful rounding
- Accomplish scheduled tasks
- Address four Ps ( position, potty, pain, possession
- Address additional personal needs, questions
- Conduct environmental asset
- Ask Is there anything else I can do for you? I have time
- Tell the patient when you will be back
- Document round
