Documentation Key Points Flashcards
Documentation
written or electronic legal record of all pertinent interactions with the patient:
-assessing
-diagnosing
-planning
-implementing
-evaluating
The patient’s record is a compilation of the …
PHI; patient’s health information
The patient document is the only permanent _____ document that details the nurse’s interactions with the _____.
legal; patient
The patient document is the nurse’s best defense if a patient or a patient surrogate alleges nursing _______.
negligence
___ information about patients is considered private or confidential.
ALL
Purpose of Patient Records
communication
diagnostic and therapeutic orders
other purposes
Patient records serve many purposes, the most important being:
communicating within health care team and providing information for other professionals
The primary purpose of the patient record is to help health care professionals from different ______ communicate with one another.
disciplines
Patient records include:
diagnostic and therapeutic orders, results of studies and related orders of care
____ handwritten notes and typos have been the source of many _____.
Illegible; errors
If you are ever uncertain of what has been written or entered in to the electronic record, _____ the _____. NEVER ______ what is written!!
check; order; guess
Verbal orders are typically only used for ____ situations when the healthcare provider is present, but unable to write the order.
emergency
The nurse must use, “_____ ____,” which is reading back the message as he or she heard and interpreted it.
read back
The person giving the order then ____ that interpretation and recording of the order is correct.
confirms
Other purposes for patient records (9)
care planning
quality process and performance improvement
research
decision analysis
education
credentialing, regulation, and legislation
legal documentation
reimbursement
historical documentation
Electronic Health Record (EHR)
digital version of patient’s chart that may contain patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and lab and test results
Personal Health Record (PHR)
information sheets that contain individual’s medical history, including diagnoses, symptoms, and medications
Progress Notes
any of a variety of methods of notes that relate how a patient is progressing toward expected outcomes
Narrative Notes
progress notes written by NURSES in source-oriented record
Charting by Exception (CBE)
shorthand method for documenting patient data that are based on well-defined standards of practice (time saver, within normal limits)
Consultation
process of inviting another HCP to evaluate patient and make recommendations
Referral
process of sending or guiding someone to another source
Purposeful Rounding
proactive, systematic, nurse-driven, evidence-based intervention that helps nurses anticipate and address patient needs
Change-of-Shift Repor
communication method used by nurses who are completing care for a patient to transmit patient info to nurses who are about to assume responsibility for continuing care
Bedside Report
standardized, streamlined shift report system at the bedside
ensures safe handoff of care
allows patient to make decisions about / be involved in their healthcare
