Documentation/Care Plans/HIPPA Flashcards
What is important to document?
EVERYTHING all subjective info - put in quotes, objective info - even if not directly related to injury, and any non verbal cues reactions to medications/tx new symptoms/rountines ongoing tx etc
What does APIE stand for?
Assess
Plan
Intervene
Evaluate
What are NURSING DO’s
Always document in 3rd person; NOT 1st
MAKE SURE YOU HAVE THE CORRECT PATIENT’S CHART(EMR) BEFORE DOCUMENTING
ACCURATE TIME,DATE, TIME OF WRITING THE NOTE AND CHART THE TIME YOU PROVIDED THE CARE
CHART PRECAUTIONS AND PREVENTATIVE MEASURES i.e. SIDE RAILS, CALLBELL,GAIT BELT
IF YOU REMEMBER AN IMPORTANT POINT AFTER COMPLETION OF YOUR NOTE ADD AS “LATE ENTRY” INCLUDE DATE AND TIME
IF A MISTAKEN ENTRY THEN WRITE “MISTAKEN ENTRY” AND NOT ERROR
What color ink should you document in
Black
Should you leave blank lines in entries?
NO - draw a line through the rest of the line and then sign your entry
What are vague terms that should NOT be used in documentation
NORMAL, good, moderate, appears, apparently
What is the nursing process for charting?
Assessment Diagnostic Reasoning Implementation Planning Evaluation
ADPIE***
What are some other things that need to be documented
PLAN OF CARE- OUTLINE OF CARE FOR THE PATIENT ADMISSION, TRANSFER,TRANSPORT AND DICHARGE INFORMATION CLIENT EDUCATION FORMAL AND INFORMAL TEACHING MATERIALS USED TO EDUCATE METHOD OF TEACHING INVOLVEMENT OF PATIENT AND FAMILY EVALUATION OF TEACHING- COMPREHENSION ANY FOLLOW UP REQUIRED
What is a CBE
Charting By Exception = a series of checklists
Dar Note
Focused note -
Data - subjective and objective info
Action - Intervention Provided
Response - Pt response to intervention
What are reasons your RN license can be suspended or revoked
Drug or alcohol abuse
Fraud, deceptive practice
Criminal acts, previous disciplinary actions
Gross or ordinary negligence (where HIPAA) falls
Physical or mental impairments including age
What are some technical safeguards for HiPAA
Access control - technical policies and procedures allowing authorized professions access
Audit controls - access is recorded an examined
Integrity controls - ensure that e-PHI is not destroyed/altered
Transmission Security - technical security measures for unauthorized access
Criminal Penalties
Criminal Penalties. A person who knowingly obtains or discloses individually identifiable health information in violation of the Privacy Rule may face a criminal penalty of up to $50,000 and up to one-year imprisonment.
What is criminal law concerned with
state and federal criminal statues and defines them (i.e murder, fraud etc)
