Documentation Flashcards
ANA Code of Ethics
“the nurse has a duty to maintain confidentiality of all patient information” -nursing students held to the same standard
Not welcome in the chart if…
not involved in their care
Who owns medical records?
The agency (hospital or facility)
Who has rights to medical records?
Patients
PHI
Protected Health Information
- identifiable health information that is transmitted or maintained.
- Includes written, verbal, electronic info
EMRs or EHRs must have…
firewall
Purposes of health care records
- communication
- planning client care
- auditing health agencies
- research
- education
- reimbursement
- legal documentation
- healthcare analysis
Source-oriented record
- traditional type of record
- organized by departments (admission, physicians, nursing, radiology, etc.)
Advantage of source-oriented records
easy to locate information from each discipline
Disadvantage of source-oriented records
data from specific problem scattered throughout chart
problem-oriented medical record
data in chart arranged to patient problems
- database
- problem list
- plan of care
- progress notes
Advantage of problem-oriented records
- team collaborates to create plan
- provides quick identification of recognized problems
Disadvantage of problem-oriented records
- charting may be lengthy, redundant
- problem list may not be kept up to date
Narrative charting
- notes that include routine care, normal findings, and patient problems
- written in an abbreviated story form
- may be used when charting abnormal findings
- use nursing process to organize data
SOAP/SOAPIE/SOAPIER note
- S - subjective; what the client says, in quotes or paraphrased without nurse’s opinion
- O - objective; what nurses observes or measures
- A - assessment; nursing diagnosis or problem
- P - plan; what will be done about the problem
- I - intervention; actions taken for problem
- E - evaluation; how did client respond to intervention?
- R - revision; changes made to plan of care
PIE Charting
- P - Problem
- I - Intervention
- E - Evaluation
omits the planning phase of nursing process
Focus charting
focus may be a condition, nursing diagnosis, patient behavior, sign and symptom, or acute change in patient condition
- D - data
- A - action
- R - response
Charting by Exception (CBE)
documentation system in which only significant findings or deviations from norms are recorded
Components of CBE
- flow sheets
- standards of nursing care
- bedside access to charts
Advantages of CBE
- elimination of lengthy repetitive notes
- flowsheets for specific entities
- reports changes in client condition
- easier to read and pick out problem areas
Disadvantages of CBE
- some nurses may feel if it is not charted, it is not done
- may want to fill in blank spaces with N/A
- may not pick up subtle changes in condition
- must know normal standards of care for healthcare organization - minimum criteria
CBE presumes…
all systems are assessed
Risks of CBE
- minimizing documentation is risky
- little description in notes could fail to alert other clinicians of potential problems
- no mention of periodic patient checks could be construed as negligence
Critical pathways
- used to document care
- emphasizes quality and cost-effective care given in pre-determined length of time
