fundamentals- chapter 7 Flashcards
1
Q
purposes of documentation
A
- provides a written record of the history, treatment, care, and response of the patient while under the care of a health care provider
- a guide for reimbursement of costs of care
- may serve as evidence of care in a court of law
- shows the use of the nursing process
- provides data for quality assurance studies
2
Q
purposes of documentation
A
- is a legal record that can be used as evidence of events that occurred or treatments given
- contains observations by the nurse’s about the patient’s condition, care, and treatment delivered
- shows progress toward expected outcomes
3
Q
documentation and the nursing process
A
- Written nursing care plan or interdisciplinary care plan is framework for documentation
- charting organized by nursing diagnosis or problem
- Implementation of each intervention documented on flow sheet or in nursing notes
- Evaluation statements placed in nurse’s notes and indicate progress toward the stated expected outcomes and goals
4
Q
the medical record
A
- Contains data about patient’s stay in a facility
- Only health care professionals directly caring for the patient, or those involved in research or
teaching, should have access to the chart - Patient information should not be discussed with anyone not directly involved in the patient’s care
5
Q
methods of documentation
A
- source-oriented (narrative) charting
- problem oriented medical record (POMR) charting
- focus charting
- charting by exception
- computer-assisted charting
- case management system charting
6
Q
source oriented (narrative) charting
A
- organization according to source if information
- separate forms for nurses, physicians, dietitians, and other health care professionals
- requires documentation of patient care in chronologic order
- Head-to-Toe assessment
- charts normals and abnormals
- lengthy and descriptive
- includes safety information
7
Q
problem-oriented medical record (POMR) charting
A
- focuses on patient status rather than on medical or nursing care
- five basic parts:
1. database
2. problem list
3. plan
4. progress notes
5. discharge summary - documents care by focusing on patient problems
- promotes problem-solving
- keeps relevant data in one place
- allows easy auditing
- not chronological
- fragments data
8
Q
focus charting
A
data, action, response (DAR)
- shortens charting time
- patient problems may be missed is database is insufficient
9
Q
charting by exception
A
- based on the assumption that all standards of practice are carried out and met with a normal or expected response unless otherwise documented
- a longhand note is written only when the standardized statement on the form is not met
- highlights abnormal data
- decreases charting time
- can lead to not charting enough
10
Q
computer-assisted charting
A
EHR
- computerized record of patient’s history and care across all facilities and admissions
CPOE (computerized provider order entry)
- provides efficient work flow
- automatically routes orders to appropriate clinical areas
- date and time automatically recorded
- notes always legible
- quick communication
- gives many providers access to info
- can reduce documentation time
- quick retrieval
- reimbursement is easier and faster
- high cost
- computer downtime can create major issues
11
Q
case management system charting
A
- organizes patient care through an episode of illness so clinical outcomes are achieved within an expected time frame and at a predictable cost
- a clinical pathway or interdisciplinary care plan takes the place of the nursing care plan
12
Q
EMR
A
electronic medical record
13
Q
EHR
A
electronic health record
14
Q
title for charting
A
E. Greene, SPN
(student practical nurse)
15
Q
PIE charting
A
P- problem identification
I- interventions
E- evaluation
