Exam 3: Chapter 19: Documenting and Reporting Flashcards
What is Documentation
Written or electronic legal record of all pertinent interactions with the patient
What is Considered Confidential
All information about patietns written on paper, spoken aloud, or saved on computer. This includes
Name, Address, Phone, Fax, SSN
REason the Person is Sick
Treatment person received
Information about past health conditions
What are the patients rights?
See and copy their health record Update their health record Get a list of disclosures REquest a restriction on certain uses or disclosures Choose how to receive health information
Purposes of Patients Records
Communication Diagnostic cand Therapeutic Orders Care Planning Quality Process and Performance Improvement Research Education Credentialing, Regulation, and Legislation Reimbursement
Methods of Documentation
Computerized Documentation/Electronic Health Records
Sourced-Oritented Records (Each organization keeps paper format in their own building).
Problem-Oriented Medical Records (Organized around a patietns problems)
PIE Charting (Problem, Intervention, Evaluation): Care plan incorporated into progress notes
Focus Charting: Bring focus of care back to the patient and the patients concerns
Charting by Exception: Shorthand documentation method that makes use of well-defibed standards of practice
Formats for Nursing Documentation
Initial Nursing Assessment Care Plan; Patient Care Sunmmary Critical Collaborative Pathways Progress Notes Flow Sheets and Graphic Records Medication Record Acuity Record Discharge and Transfer Summary Long-Term Care Documentation
Initial Nursing Assessment
Typical electornic form used to record the initial database obtained from the nursing history and p hysical assessment
Care Plan; Patient Care Sunmmary
Patient records must communicate the patietns problems or diagnoses; related goals, outcomes, and interventions; and progress or resolution of the problems
Critical Collaborative Pathways
Case management plan is detailed, standardized care plan that is developed for a patient population with a designated disnogsis or procedure
Progress Notes
Purpose of progress notes is to inform caregivers of the progress a patient is making toward achieveing expected outcomes
Flow Sheets
Documentation tools used to efficiently record routine aspects of nursing care
Graphic Record
A form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight fluid intake and output, bowel movements, and other patient characteristics
Medication Administration Records (MAR)
The patients medication record must include documentation of all medications administered to the patient, the nurse administering the drug, and for some medications, the reason teh drug was administered
Acuity Records
When the nurse ranks patients as high-to-low acuity in relation to both the patients condition adn need for nursing assistance or intervention
Discharge Summary
Should be written and concisely summarize the reason for treatment, significant findings, the procedures performed and treatment rendered
