Documentation Flashcards
what is the purpose of documentation?
communication health care analysis auditing research reimbursement education legal documentation planning client care
how does documentation serve as a form of communication?
health care workers are able to communicate with other health care workers
how does documentation allow for planning client care?
use of baseline data to prescribe and care
how does documentation help health care analysis?
help determine needs and under and over utilized services
how does documentation help research?
data can help build treatments
how does documentation help education?
students like me!
how does documentation help audit health agencies?
is the health agency meeting its standards?
how does documentation help reimbursement?
insurance, medicare, medicaid
how does documentation help with legal documentation?
it can serve as evidence in court
“the nurse has a duty to maintain confidentiality of all patient information”
ANA code of ethics
what are a few critical issues in documentation
opinons vs. facts careful faxing incorrect spelling don't write error! dont erase
what are the federal regulations for documentation
medicare and medicaid
what are the state and federal regulations of documentation
JCAHO
what are the different types of reports
change of shift telephone reports telephone roders care plan conferences nursing rounds
what does a nursing round consist of?
2+ nurses to obtain info, evaluate care and include patient on care
what does SBAR stand for?
situation
background
assessment
recommendation
what are the verbal handoff communication tools?
I PASS the BATON
I SBAR
PACE
5 P’S
what does I PASS the BATON stand for?
intro, patient, assessment, situation, safety, concern, background, actions, timing, ownership and next
what does PACE stand for?
patient/problem, asssessment/actions, continuing treatment/changes, and evaluation
what are the 5 P’S
patient plan purpose problems precautions physician
what is a POLST?
provider’s order for life sustaining treatment
objective and nonjudgemental
accurate timely and pertinent
summary of activities, observations, and actions performed are all included in what?
reporting
closed loop communication ensures information conveyed from sender is understood by receiver as intended
check back
how do we communicate when we are concerned?
cus
what does cus stand for
i am CONCERNED
i am UNCOMFORTABLE
this is a SAFETY ISSUE
when is an incident report used?
when any event not consistent with routine care of a client
what is a flow sheet?
quick nursing data including….
graphic record
intake and output record
med administration record
skin assessment record
what is a kardex?
organization and recording method for data on client
documentation system in which only abnormals are charted
charting by exception
clients concern and strengths the focus, usually in three columns
focus charting
goal not met in critical thinking
variance
