Documentation And Informatics Flashcards
Consultations
Another form of discussion in which one professional caregiver gives formal advice about the care of the patient to another caregiver
Referrals
An arrangement for services by another care provider
Purposes of records
Communication Legal documentation Reimbursement Education Research Auditing and monitoring
Guidelines for quality documentation and reporting
Factual Accurate Complete Current Organized
Electronic health record (EHR)
Electronic record of the patient’s health information gathered whenever the patient excesses medical care in any healthcare delivery setting
Electronic medical record (EMR)
Contains patient data gathered in a healthcare setting and I specific time and place and is part of the EHR
Problem oriented medical record (POMR)
Method of documentation that emphasizes patients problems.
Database – all available assessment information pertaining to the patient
Problem list- patient’s psychological, physiological, social, cultural, spiritual, developmental, and environmental needs
Care plan
Progress note-S.O.A.P., P.I.E., D.A.R.
Formats for progress notes
S.O.A.P.I.E.-subjective data, objective data, assessment, plan, intervention, evaluation.
P.I.E.-problem, intervention, evaluation.
Focus charting –D.A.R.-Data, action, response.
Source record
Patient’s chart that has a separate section for each discipline to record data.
Charting by exception
Focuses on documenting deviations from established norms
Case management model of delivering care
Incorporates an interdisciplinary approach to documenting patient care
Critical pathways
Interdisciplinary care plans that include patient problems, key interventions, and expected outcomes within an established timeframe
Variances
Unexpected outcomes, unmet goals, interventions not specified within the critical pathway, can be positive or negative
Admission nursing history form
Provides baseline data to compare with changes
Flowsheet
Allows you to quickly and easily enter assessment data about patient
