Documentation, Reporting, & Informatics Flashcards
Documentation
the act of making a written record
recording; charting
clear, comprehensive yet concise, complete, correct
Written, electronic, or both
By 2024, push to all electronic
Medical, now refer to as health record
20.6%
% of time spent by RN’s in the workday documenting & reviewing the e-health record
Documenting throughout ADPIE
Why Is Documentation Important?
- For education & research
- Enhance team communication
- Continuity of care
- Quality improvement (chart audits)
Why Is Documentation Important? cont’d
- Monitor patient outcomes over time
- Is a legal record
- Identify standards of care
- Helps with reimbursement & utilization review
Need For Standardized Language
- Make nursing visible
- Support nursing research
- Provides standardized terminology for use in EHR systems
- Helps in transition to electronic systems
NANDA-I
NIC & NOC
GE Healthcare Epic Meditech Siemens Healthcare Cerner
- Source-oriented vs problem-oriented record systems
- Charting by exception
- Expensive
- Frequent updates → downtime
- Lack of integration between units/departments
- Paper records (familiarity)
Document Using The Nursing Process
Assessment
- Chart signs and symptoms that may indicate actual or potential client problems. At initial, document comprehensive data about all client symptoms
Document Using The Nursing Process cont’d
Diagnosis
- After analyzing assessment data, document your clinical nursing judgment about the client’s response to actual or potential health conditions or needs
Document Using The Nursing Process cont’d
Planning Outcomes/Interventions
- Document measurable and achievable short and long-term plan of care with goals directed at preventing, minimizing, or resolving identified client problems/issues
Document Using The Nursing Process cont’d
Implementation
- After plan of care in effect, record specific interventions used
Document Using The Nursing Process cont’d
Evaluation
- Document client responses to nursing care; chart whether plan of care was effective in preventing, minimizing or resolving the identified problems; modify plan as needed
Formats For Nursing Progress Notes
?
Organizes info according to the client problems
Eliminates the need for a separate care plan
Does not enhance holistic care
Nursing-focused rather than medical-focused
Doesn’t document in planning portion of nursing process
Problem-Intervention-Evaluation (PIE)
?
Used with source-oriented and problem-oriented charting
Useful when trying to demonstrate a timeline of events (i.e. cardiac arrest)
Can result in lengthy notes
Clinicians may not read (focus on EHR)
Story of client’s experience in order it happens
Narrative
?
Only exceptions to norm or significant info
Is based on the charting by exception model
Fact documentation
?
View from client perspective
Concern can be nursing diagnosis, sign or symptoms, client behaviors, a special need, acute change in condition, or a significant event
Data-Action-Response (DAR)
Data [Assessment]
Action [Planning/Implementation]
Response [Evaluation]
Holistic
Lack of common problem list may lead to inconsistent labeling of the focus of notes; thus causes difficulty in tracking client progress
Focus charting
?
Subjective data, Objective data, Assessment (inferences/conclusions), Plan, Interventions, Evaluation, Revision
Can be inefficient and ineffective
Shifts focus from client to illness
Problem list, initial plan, progress notes, discharge summary
SOAP/SOAPIE/SOAP(IER)
Joint Commission’s List of “Do Not Use” Abbreviations
See W&T Volume II
Ch 18 p. 183 - Common Healthcare Abbreviations
Ch 26 p. 499 - Medical Abbreviations
Forms Used To Document Nursing Care
Nursing Admissions Data Forms
Discharge Summary
Flowsheets
Checklists
Intake and Output (I&O)
Medication Administration Records (MAR)
