Final: Documentation Flashcards
Documentation is a written account of
Patient data
Clinical decisions and interventions
Patient response
Provider entrance/exit from chart
Documentation must be
Accurate and comprehensive: IT reflects the quality of care
Effective documentation:
Helps ensure continuity of care
Saves time
Minimizes the risk of errors
If you didn’t document it
You didn’t do it!!
Mistakes that commonly result in malpractice include failing to record
Health/drug into Nursing actions taken Medications administration/withheld Drug reactions or change of conditions Discontinuation of medications Completely and legible
Purposes of medical record
Communication Legal documentation Reimbursement Education Research Auditing/monitoring
Face characteristics of documentation
Factual Accurate Complete Current and timely Organized
Document the following at the time of occurrence
Vitals/pain assessment
Med/TX
Prep for tests, procedures, surgeries
Change in status/condition and who was notified
Admit, transfer, discharge, death of patient
Tx for any sudden change
Patient response to tx/intervention
Avoid vague terms like
Appears, seems, apparently
Methods of documentation for progress notes
SOAP
SOPAIE
PIT
DAR
Recapitulaiton of stay
Final summary at discharge/death
Oasis assessment
Collect and report assessments and outcomes
