Documentation and reporting Flashcards
Nursing action that produces a written account of pertinent patient data, nursing clinical decisions and interventions and patient’s responses in health record
Documentation
Purposes of Medical Record
Communication
Legal documentation
Reimbursement
Auditing and Monitoring
Research
Education
Ethical Considerations
Privacy, Confidentiality
Guidelines for quality documentation
Factual
Accurate
Complete
Current
Organized
traditionally used to record patient assessment and nursing care provided
Narrative
system of organizing documentation to place the primary focus on patient’s individual problems
Problem-Oriented Medical Record
contain all available assessment information pertaining to a patient
data base
includes patient’s physiological, psychological, social, cultural, spiritual, developmental and environmental needs
problem list
HC team members monitor and record the progress made toward resolving patient’s problems in
POMR, SOAP (Subjective data, Objective data, Assessment (diagnosis based on the data), Plan (what the caregiver plans to do)
SOAPIE (Intervention, Evaluation)
Progress Notes
Common record-keeping forms
Admission Nursing History Form
Flowsheets and Graphic records
Patient care summary
Standardize care plans
Discharge Summary Form
Documenting, communications with providers unique events
Telephone calls
Telephone or Verbal orders
Incident reports
occur when a HCP gives therapeutic orders over the phone to a RN
telephone order
occur when a HCP gives therapeutic orders to a RN while they are standing in proximity to one another
verbal orders
any event that is now consistent with the routine, expected care of the patient or the standard procedures in place on a health care unit
incident reports
