Documentation, Electronic Health Records, and Reporting Flashcards
Health care documentation is
any written or electronically generated information about a patient that describes the patient, the patient’s health, and the care and services provided, including the dates of care
Health care documentation records may be both ______ and ______ written
electronic and paper
medical record for each patient that is accessed only by
authorized personnel
documintation include
reasons for each patient encounter, including assessments and diagnosis;
the plan of care,
the patient’s progress,
any changes in diagnosis and treatment,
the date, and the identity of the observer
medical record is
a document with comprehensive information about a patient’s health care encounter, as well as demographic, administrative, and clinical data.
the medical record is considered a _______ document
legal
medical record must meet guideline for
completeness
accuracy
timeliness
accessibility
authenticity
The record can be used to
assess quality-of-care measures
determine the medical necessity of health care services
support reimbursement claims
protect health care providers patients and others in legal matters
The use of paper medical records requires no ______ ______ _______
special technical training
. Paper medical records are now rarely used except in cases of
electronic system downtime due to power outages or mass disasters
When using paper documentation, nurses are responsible for knowing how to
correctly spell and document events
electronic medical record (EMR) is
longitudinal record of health that includes the information from inpatient and outpatient episodes of health care from one or more care settings
Health information comprises patient data such as
demographics, assessment findings, flow sheets that include point-of-care results, diagnoses, nursing treatments, and a medication profile listing historical and currently active medication orders
Computerized provider order entry (CPOE) allows clinicians to
enter orders in a computer that are sent directly to the appropriate department
Decision support in the electronic record may include
medication interaction screening and reminders for preventive health actions, such as vaccinations
The electronic record provides
connectivity to enhance communication between all members of the health care team
EHR supports administrative processes with more efficient and timely data abstraction for
scheduling, billing, and claims management
All healthcare personnel must have a basic level of
computer competency in addition to an understanding of documentation principles
Documentation should be
factual, accurate, and nonjudgmental, with proper spelling and grammar. Events should be reported in the order they happened, and documentation should occur as soon as possible after assessment, interventions, condition changes, or evaluation
Nursing documentation is guided by the five steps of the nursing process:
assessment, diagnosis, planning, implementation, and evaluation
problem-oriented medical record (POMR) integrates
charting from the entire care team in the same section of the record
Do-Not-Use Abbreviations are:
U, u (unit)
IU (international unit)
QD, Q.D., qd, q.d. (daily)
QOD, Q.O.D., qod, q.o.d (every other day)
MS, MSO4, and MgSO4
Trailing zero (X.0mg)
Lack of leading zero (.X mg)
Problem-Oriented Medical Records Formats
PIE
APIE
SOAP
SOAPIE
SOAPIER
DAR
CBE
PIE stands for
Problem, intervention, evaluation
APIE stands for
Assessment, problem, intervention, evaluation
SOAP stands for
Subjective data, objective data, assessment, plan
SOAPIE stands for
Subjective data, objective data, assessment, plan, intervention, evaluation
DAR stands for
Data, action, response
CBE stands for
Charting by exception
SOAPIER stands for
Subjective data, objective data, assessment, plan, intervention, evaluation, revisions to plan
Narrative charting is
chronologic, with a baseline recorded on a shift-by-shift basis
Narrative charting may stand alone or may be complemented by other tools, such as
flow charts, flow sheets, and checklists
Charting by exception (CBE) is
documentation that records only abnormal or significant data
Case Management Documentation is focused on
providing and documenting high-quality, cost-effective delivery of patient care
The goal of case management is
to achieve realistic and desired patient and family outcomes within appropriate lengths of stay and with appropriate use of resources
Flow sheets and checklists within the EHR may be used to
document routine care and observations that are recorded on a regular basis, such as vital signs, medications, and intake and output measurements
medication administration record (MAR) is
list of ordered medications, along with dosages, routes, and times of administration, on which the nurse initials medications given or not given
If a medication is not given, the nurse should
note the reason on the MAR
Documentation in the EHR is a
legal record of patient care
The medical record is seen as
most reliable source of information in any legal action related to care
Health Insurance Portability and Accountability Act (HIPAA), originally passed in 1996, created standards for
the protection of personal health information, whether conveyed orally or recorded in any form or medium
confidentiality in health record means
being entrusted with private patient information
hand-off is
The real-time process of passing patient-specific information from one caregiver to another or among interdisciplinary team members to ensure continuity of care and patient safety
Hand-offs can be
oral, as in a face-to-face meeting or telephone communication, or they can be written, recorded, or printed from the EHR
sentinel event is
safety occurrence that affects a patient and causes death, serious permanent or temporary injury, or requires interventions to sustain life
SBAR stands for
situation, background, assessment, and recommendation
