Documentation Flashcards
Purpose of a medical record (7 things)
Communication Legal documentation Education Reimbursement Education Research Auditing/monitoring
Why the shift to electronic documentation?
decrease cost, improve pt care
What is confidential?
EVERYTHING
What are the 7 things you need to have an assessment of when documenting?
Physical Psychological Environmental Self care Knowledge level Discharge planning Pt & family planning
Guidelines for QUALITY documentation (5)
Factual-objective Accurate-clear, easy to read Complete Current Organized
3 Methods of reporting
Charting by Exception (CBE)
Critical (clinical) Pathways
Case Management Plans
Methods of documentation
Narrative (traditional method)
Problem-oriented medical record (POMR)
this form of documentation has details in step by step fashion–rare
Narrative method of documentation
This form of documentation has databases, the patient’s problem list, the current care plan, and the progress notes meaning what went on throughout your shift.
POMR
SOAP
Subjective, objective, assessment (diagnosis), Plan
SOAPIE
Subjective, objective, assessment, plan, intervention, evaluation (similar to nursing assessment)
PIE
Problem (diagnosis), intervention (what was done in order to address problem), evaluation
Focus Charting (DAR) focuses on client needs from variety of perspectives
Data, action, response
Charting by Exception (CBE) is commonly used in
electronic documentation
checking off “normal” box
charting only if something is abnormal
flowsheets, checklists
Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient
Incident or occurence reports
What are discouraged in hospital setting?
verbal orders (VO)
Common Record-Keeping Forms
Admission nursing history form Flow sheets and graphic records Patient care summary Standardized care plans or clinical care guidelines (CPGs) Discharge summary forms
Preprinted, established guidelines used to care for patients who have similar health problems
Standardized care plans or clinical care guidelines (CPGs)
Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems
Admission nursing history form
Help team members quickly see patient trends over time and decrease time spent on writing narrative notes
Flow sheets and graphic records
Most recent data
Put in patient chart if needed
Typically printed out once a day
Patient care summary
Documentation needs to conform to standards of the _______ & _____ to maintain institutional accreditation and minimize liability
National Committee for Quality Assurance (NCQA) & TJC
