documenting Flashcards
purposes of patient records
communication, diagnostic & therapeutic orders, care planning, legal, historical documentation, research, education, credentialing, reimbursement, quality improvement
elements of documentation
avoid words “good” & “average” “pt is an angry old man”/ never document beef interventions are carried out/ never skip lines
what is confidential
all info about pts written on paper, spoken aloud, saved on computer/ reason the person is sick/ treatment the pt receives/ info about past health conditions/ HIPAA
what does HIPAA stand for
health insurance portability and accountability act
potential breaches in pt confidentiality
displaying info on public screen/ sending confidential email messages via public info/ discarding copies of pt info in trash cans/ conversations in cafe, elevator, break room/ faxing info to unauthorized persons/ confidential messages over pagers
when correcting an error, what do you do
draw single line through the error, above is write error and your initials
last name and status when charting
T. Kurtz, KSU, SN
what to chart
assessment at start of shift, changes in mental psychological physiological conditions, reactions to procedures or medications, teaching ( document what was taught and the clients response), physician visits, time client left and returned to unit, medications, treatments
formats for nursing documentation: initial nursing assessment
baseline for later comparison
formats for nursing documentation: care plan
communicate problems, goals, interventions
formats for nursing documentation: patient care summary
overview of valuable pt data
formats for nursing documentation:progress notes
info caregivers/ providers of progress pt is making / SOAP notes
formats for nursing documentation: flow sheets and graphic records
flow sheets: quickly document aspects of patine care/ graphic record: form used to record specific variables such as vs, weight, I & O
formats for nursing documentation: medication record (MAR)
must include all meds administered to the pt. also include nurse giving the drug, reason drug was ordered and its effectiveness
formats for nursing documentation: discharge and transfer summary
summarize reason for tx, significant findings, procedures performed, tx rendered. the pts condition on D/C should also be recorded
formats for nursing documentation: home healthcare/ long term documentation
ensure continuity of care. sent to third party payers, which establish need for continuing home health care as well as reimbursement for necessary services
SOAP / SOAPIE
subjective, objective, assessment, plan/ documents one problem at time (implantation, evaluation)
CBE
charting by exception/ document only abnormal or significant findings
EHRs
computerized documentation/ electronic health records
MAR
medication administration record
incident is not
apart of the pts health record
purposeful rounding, 4 P’s
potty, pain, position, and personal surroundings
improvements from purposeful rounding
pt satisfaction scores, reduction in pt falls, reduction in call light use, decline in skin breakdown
when recording a verbal order (VO) or telephone order (TO)
date and note the time orders were issued in emergency, followed by physicians name and nurses name and initials
SBAR/ ISBARR
situation, background, assessment, recommendation/ identify or introduction, situation, background, assessment, recommendation, read back
