Documentation & Reporting (Exam 2) Flashcards
What are the purposes of a patients medical record?
COMMUNICATION
continuity of care (communication among healthcare team)
legal record of care
reimbursement
quality improvement
accreditation
research
educational tool
What is included in documenting regarding entering data about the patient?
assessment
intervention
nursing care
patient response to care
Documentation must be…
OBJECTIVE AND PRECISE!! DOCUMENT EVERY 1-2 HRS
Avoid conjecture, best to describe what you see instead of assuming (“seems agitated”)
Avoid vague terms (“pain is better”, “good skin color”)
Be factual (who found the fallen pt?)
don’t use unapproved abbreviations
“no further concerns as of present”
When documenting, you should be cautious with..
ABBREVIATIONS (HOSPITAL APPROVED LIST, JC DO NOT USE)
What abbreviations are on the JC DO NOT USE list, and what should you use instead?
U/u unit
IU International unit
Q.D/QD/Q.O.D/QOD write daily or every other day
trailing 0/lack of leading 0. write X mg or 0.X mg
MS/MSO4/MgSO4 write morphine sulfate or magnesium sulfate
How to correct errors when documenting
draw single line, no white out
write mistake entry with date and initials
CAN EDIT IN EMR, SYSTEM KEEPS RECORD
When should you document?
admission
transfer
discharge
ongoing care per policy
change in condition
communication
When can protected health information be released?
treatment
payment
normal healthcare operations
Potential violations of HIPAA
discussing patients in public areas
leaving charts out
not logging off computers
copying forms
social media
Verbal Orders
INCREASE RISK OF ERROR
VORB- Verbal Order Read Back
must be signed by prescriber ASAP
Telephone Orders
READ BACK, SPELL UNFAMILIAR NAMES, PRONOUNCE DIGITS SEPARATELY
RECORD WITH DATE, TIME AND TORB-Telephone Order Read Back
must be co signed within 24 hours
Source-Oriented Documentation
disciplines charted separately
data scattered, may lead to fragmentation
Problem-Oriented Documentation
organized around clients problems and allows for greater collab
FOUR PARTS: DATABASE, PROBLEM LIST, PLAN OF CARE, PROGRESS NOTES
Narrative Charting Documentation
use with source and problem systems
chronological story of care
tracks client changing status
can be lengthy and disorganized
PIE Charting
Problem
Interventions
Evaluation
problem oriented, establishes ongoing plan of care
SOAP(IER) Charting
Subjective Data
Objective Data
Assessment
Plan (short term and long term goals)
Intervention
Evaluation
Revision (of evaluation)
Focus Charting
highlights clients concerns, problems or strengths in 3 columns
1: Time and date
2: Focus or problem being addressed
3: Charting in DAR format
DAR Format
Data
Action
Response
Charting by Exception
charting only significant findings or exception to norms
drop down boxes and checklists
OMISSIONS BIGGEST PROBLEM
do not just follow previous shift, assess what is normal in the moment
FACT Documentation
Flow sheets (individualize specific services)
Assessment (baseline data)
Concise (progress notes)
Timely entries
What are the advantages of EMR?
decreased error
more legible
improved access
quality control
cerner/EPIC
Integrated Plans of Care (IPOC): Critical Pathways
based on EBP
specific group of patients with predictable clinical diagnosis
maps out from admission to discharge, interventions are defined
What are the components of the record?
face sheet
graphics
flow sheet
progress notes
H+P
consults
operative report
orders
MAR
Lab
Diagnostics
Nursing Admission Assessment
baseline data from which to monitor change; discharge planning information/needs
