Documentation Power Point Flashcards
Nurses are _____ and ethically obligated to keep all patient information confidential.
legally
Nurses are responsible for ______ records from all unauthorized readers.
protecting
_____ requires that disclosure or requests regarding health information are limited to the minimum necessary.
HIPAA
______ is anything written or printed as proof of patient actions and activities.
documentation
The care provided as ______ or charting; it should reflect the nursing process.
documentation
______ is a vital aspect of nursing practice.
documentation
Information to document
Assessments
Medications
Treatments and responses
Client education
Current documentation standards require that each _____ have an assessment that includes physical, psychosocial, environmental, self-care, patient education, knowledge level, and discharge planning needs
patient
Nursing _____ standards are set by federal and state regulations, state statutes, standards of care, and accreditation agencies.
documentation
_____ are when a professional caregiver giving formal advice to another caregiver
consultations
____ are arrangement for services by another care provider.
referrals
Interdisciplinary communication withing the health care team provides _______ among all team members who provided care to the same clients.
continuity of care
Remember, if it wasn’t ______, it wasn’t done!!
documented
Purposes of Records
communication legal documentation financial billing/reimbursement client education research auditing/monitoring
Legal Guidelines for Recording
Correct all errors promptly, using the correct method.
Record all facts; do not enter personal opinions.
Do not leave blank spaces in nurses’ notes.
Write legibly in permanent black ink.
If an order was questioned, record that clarification was sought.
Chart only for yourself, not for others.
Avoid generalizations.
Begin each entry with the date/time and end with your signature and title.
Keep your computer password secure.
Guidelines for Quality Documentation and Reporting
Factual Accurate Complete Current Organized Nonjudgmental Timely Concise
Common charting mistakes include failing to document _____ medications
discontinued
Common charting mistakes include writing illegible or _____.
incomplete records
Common charting mistakes include failing to record pertinent health & drug info, nursing actions,
that medications have been given, _____ or changes in client’s condition
drug reactions
Methods of recording include a ___ record which is episode oriented, but key info ay be lost form one episode ot another.
paper
Methods of recording include ____ which is a digital version of a patient’s medical record. It integrates all of a patient’s info in one record and improves continuity of care.
electronic health record (EHR)
____ is the traditional method of recording.
narrative
_____ is a method of recording that is a database that includes a problem list, care plan and progress notes.
problem oriented medical record (POMR)
Methods of recording: progress notes include SOAP which stands for:
subjective
objective
assessment
plan
Methods of recording: progress notes include SOAPIE which stands for:
subjective objective assessment plan intervention evaluation
Methods of recording: progress notes include PIE which stands for:
problem
intervention
evaluation
Methods of recording: progress notes include Focus Charting or (DAR) which stands for:
Data
Action
Response
CBE in documentation stands for ___.
charting by exception
____ are a separate section for each discipline to document.
source records
CBE focuses on documenting ____.
deviations
Case management plan and critical pathways incorporate a muldisciplinary approach to _____ and variances.
care
_____ is a multidisciplinary approach to document client care
critical pathways
Standardized plan of care is summarized into ____ with a case management plan.
pathways
Critical pathways include a ____page integrated care plan for problems and includes key interventions and expected outcomes.
1-2
_______ Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems
admission nursing history form
______ Help team members quickly see patient trends over time and decrease time spent on writing narrative notes
flow sheets and graphic records
_____ is a A portable “flip-over” file or notebook with patient information
patient care summary or Kardex
_____ are a Preprinted, established guidelines used to care for patients who have similar health problems
standardized care plans
Common record keeping forms also include the ____ summary forms and acuity records.
discharge
Forms that may be used by nurses
Progress notes
Flow sheets
D/C summaries
Client education
Kardexes
MARs (Medication Administration Records)
What to document?
Your interventions w/ patient’s response and your evaluation Any significant changes or events in condition Informed consent Patient teaching Any attempts to contact medical staff Patient leaving AMA Patient’s refusal of treatment Spiritual concerns Use of restraints Medication Administration
Medicare has specific guidelines for establishing eligibility for _____.
home care
_____ guidelines for establishing a patient’s home care cost reimbursement serve as the basis for documentation by home care nurses.
Medicare
______ is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance.
Documentation
Nurses need to document all their services for .
payment
Governmental agencies are instrumental in determining standards and policies for ______.
documentation
The ______ of 1987 includes Medicare and Medicaid legislation for long-term care documentation.
Omnibus Budget Reconciliation Act
The department of health in states governs the _____ of written nursing records.
frequency
Reporting Care
Change-of-shift Hands off care Telephone report to MD Transfer/Discharge reports Oral Written Computer-based
A ____ report occurs with transfer of patient care and provides continuity and individualized care.
Reports are quick and efficient.
hand-off
_______ include Situation-background-assessment-recommendation (SBAR) and make sure to document every call and Read back the orders.
telephone reports and orders
_______ are Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient.
Follow agency policy.
incident or occurrence reports
_____ is a Report written about any event not consistent with routine operation of the HC unit or routine care of the client
incident/occurrence report
An incident/occurrence report should be ______, accurate report exactly what is observed + F/U care given
Concise
An incident/occurrence report is part of quality ______with the institution
improvement
An incident/occurrence report investigates the occurrence/circumstances and
may result in ____ that are needed to prevent recurrences
changes
Critical Elements of an incident report
Date/time of occurrence How nurse found the client Witness info Assessment of client’s injury Actions taken + FU notations Who finds/witnesses the incident writes the report Not part of the medical record
_____ is A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice
nursing informatics
_____ is a group of systems used in a health care organization to support and enhance health care
Health Care Information System (HIS)
_____ Consists of one or more
Computerized clinical information systems (CISs) and/or
Administrative information systems
nursing informatics
Advantages of NISs
IIncreased time to spend with patients Better access to information Enhanced quality of documentation Reduced errors of omission Reduced hospital costs Increased nurse job satisfaction Compliance with accrediting agencies Common clinical database development
Protection of the confidentiality of patients’ health information and the security of computer systems are ____ that include log-in processes, audit trails, firewalls, data recovery processes, and policies about handling and disposing of data to protect patient information.
top priorities
You, and only you, should chart the care you give and _____ State’s Nursing Practices Acts prohibit having another chart for you on medical records.
supervise.
____ of all malpractice suits are decided based on documentation (or lack thereof).
One fourth
