FON DOCUMENTATION Flashcards
is the process of making an entry on a client record.
Documentation
any written or electronically generated information about a client that describes the status, care or services provided to that client.
Documentation
Record of nursing care that is planned and delivered to individual patients by nurses.
Documentation
A vital component of safe, ethical and effective nursing practice.
Documentation
According to _______ documentation requires client record to be timely, complete, accurate, confidential and specific to the client.
JCAHO
According to _____ the nurse has a duty to maintain confidentiality of all patient information.
ANA
According to _______ accurate documentation of actions and outcomes of delivered care is the hallmark of nusing accountability.
code of ethics for FIlipino Association
According to ________ thet maintain the privacy and confidentiality of 18 protected health information.
HIPAA
Purposes of Clients Record
-Communicatio
-Planning Client Care
-Auditing Health Agencies
-Research
-Education
-Reimbursement
-Legal Documentation
-Health Care Analysis
It is a purpose of clients records that prevents repetition, and delays in care
communication
It is a purpose of clients records where nurses use ongoing data to evaluate effectiveness of the care plan
Planning client Care
It is a purpose of clients records that review client record for quality assurance purposes
Auditing health agencies
It is a purpose of clients records where treatment plans for a number of client with same health problems can yield information.
Research
It is a purpose of clients records where students in health discipline often use client records as educational tools
Education
It is a purpose of clients records that helps facility receive reimbursement from federal government
Reimbursement
It is a purpose of clients records that is admissible in court as evidence
Legal Documentation
It is a purpose of clients records that assist health care planners to identify agency needs such as overutilized and underutilized hospital services
Health Care Analysis
MEASURES USE TO MAINTAIN THE CONFIDENTIALITY AND SECURITY OF COMPUTERIZED CLIENT RECORDS
-Confidientiality of all patient information.
-Client’s record protected legally as a private record of client’s care.
-HIPAA regulations updated on April 14, 2003
-Responsibility in using records for the purpose of education and research
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The following are some suggestions for ensuring confidentiality and security of computerized records:
-A personal passwords is required to enter and sign off computer files. (in a month changes 3 times)
-Personal passwords should not be shared.
-Never leave the computer terminal unattended after logging on.
-Do not leave client information displayed on the monitor where others may see it.
-Shred all unneeded computer-generated worksheets. (10-20 years ago)
-Know the facility’s policy and procedure for correcting an entry error.
-Follow agency procedures for documenting sensitive material such as a diagnosis of AIDS.
-Information technology (IT) personnel must install a firewall to protect the server from unauthorized access.
DISCUSS THE DIFFERENT SYSTEM USED IN DOCUMENTING HEALTH CARE ACTIVITIES AND INTERVENTIONS
-Source-oriented record
-Problem-oriented medical records
-PIE
-Focus Charting
-Charting by exception
-Computerized records
-The case management model
Narrative Charting is what system?
Source - Oriented Record
Traditional Client Record
Source - Oriented Record
Information about a particular problem distributed throughout the record.
Source - Oriented Record
Convenient because care providers can easily locate the forms.
Source - Oriented Record
Consist of written notes that include routine care, normal finding, and client problems.
-There is no right and wrong order to the information, although chronologic order is frequently used.
Narrative Charting
Data are arranged according to the client problem.
Problem - Oriented Medical Records
Members of the health care team contribute to the problem list , plan of care, and progress notes
Problem - Oriented Medical Records
Encourages collaboration and easier to track status of problems
Problem - Oriented Medical Records
Disadvantages of problem-oriented medical records
-Caregivers differ in their ability to use the required charting format.
-Takes constan vigilance (watchfulness) to maintenance an up-to-date problem list.
-Somewhat inefficient because assessments and interventions that apply to more than one problem must be repeated.
4 Basic Components of Problem - Oriented Medical Records
-Database
-Problem list
-Plan of care
-Progress notes
All information known about the client where first enter agency.
Database
Listed in order in which they are identified and others resolved.
Problem list
Made with references to active problems.
Plan of Care
Made by all health professionals involved in a client’s care.
Used SOAP, SOAPIE, SOAPIER Documentation
Progress Notes
What is the meaning of the mnemonic SOAPIER
S-SD
O-OD
A-SSESSMENT
P-PLAN
I-NTERVENTON
E-VALUATION
R-EVISION/REASSESSMENT
Ongoing client assessment flow sheet and progress notes.
PIE
Focus on client concerns and strengths. ex: acute pain
Progress notes organized into DAR format
Focus Charting
What does the mnemonic DAR means
Data - Assessment Phase
Action (intervention) “as per doctor’s order” - Planning and implementing phase
Response - Evaluation Phase
Incorporation of:
-Flow sheets
-Standards of nursing care
-Bedside chart forms
Charting by exception
Agencies develop standards of nursing practice
Charting by exception
Documentation according to standards involves a check mark.
Charting by exception
Exceptions to standards described in narrative form on nurse’s notes.
Charting by exception
Developed to manage volume of information
Computerized Documentation
Used by nurses to:
-Store client’s database, new data
-Create and revise care plans
-Document client’s progress
Information easy to retrieve
Computerized Documentation
Speech-rate recognition technology
-Nurse must be alert and aware of others who might hear the dictation.
Computerized Documentation
-Possible to transmit information from one care setting to another.
-Confidentiality is at risk
Computerized Documentation
-Quality, cost-effective care delivered within established length of stay.
-Uses multidisciplinary approach, critical pathways, CBe
Case Management Model (patient na gumaling)
A goal that is not met
Variance
Documentation of variances include:
-Actions taken to correct the situation
-Justification of actions taken
-Completed when client discharged
-Completed when client transferred to another institution
NURSING DISCHARGED/ REFERRAL SUMMARIES
-Based on professional standards, federal and state regulations, policies of health care agency.
LONG-TERM CARE DOCUMENTATION
Laws and Requirements of LONG-TERM CARE DOCUMENTATION
-Health care financing administration
-Omnibus Budget Reconcilation Act (OBRA) of 1987
-Medicare and Medicaid
It is influenced by:
-Health Care Financing Administration (1985)
-Medicare and Medicaid
-Other third party payers
HOME CARE DOCUMENTATION
Two records that are required in HOME CARE DOCUMENTATION
-Home health certification and plan-of-treatment form
-Medical update and patient information form
Used to guide documentation practice
FACT
Objective information about what an RN see, hears, feels, and smells
Factual
the use of exact measurements and established accuracy.
Accurate
charting must be complete, including appropriate and essential information.
Complete
to reflect a clear record of what has happened
Timely
What are the purposes of Records
-Communication
-Planning Client Care
-Auditing Health Agencies
-Research
-Education
-Reimbursement
-Legal Documentation
-Healthcare Analysis
Documentation System
-the source-oriented record;
-the problem-oriented medical record;
-the problems, interventions, evaluation (PIE) model;
-focus charting;
-charting by exception (CBE);
-computerized documentation;
-case management.
The POMR has four basic components:
- Database
- Problem list
- Plan of care
- Progress notes
