fundamentals- chapter 7 Flashcards
purposes of documentation
- 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
purposes of documentation
- 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
documentation and the nursing process
- 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
the medical record
- 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
methods of documentation
- source-oriented (narrative) charting
- problem oriented medical record (POMR) charting
- focus charting
- charting by exception
- computer-assisted charting
- case management system charting
source oriented (narrative) charting
- 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
problem-oriented medical record (POMR) charting
- 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
focus charting
data, action, response (DAR)
- shortens charting time
- patient problems may be missed is database is insufficient
charting by exception
- 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
computer-assisted charting
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
case management system charting
- 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
EMR
electronic medical record
EHR
electronic health record
title for charting
E. Greene, SPN
(student practical nurse)
PIE charting
P- problem identification
I- interventions
E- evaluation
accuracy in documentation
- be specific and definite
- use words or phrases that convey the correct
meaning - words with ambiguous meanings and slang should not be used
brevity in documentation
- articles may be omitted (a, an, the)
- use abbreviations, acronyms, symbols acceptable to the agency
- choose which behaviors and observations are noteworthy
legibility and completeness in documentation
- if writing is not legible, misperceptions can occur
- include as much information as needed
- must see patient and document something at least every 2 hours (rounds)
- completeness is more important than brevity
admission forms
intake and output (I&O) record
ancillary staff sheets
consultation sheet
diabetes care flow sheet
discharge form
discharge planning sheet
fall risk assessment
frequent observations sheet
intravenous (IV) flow sheet
pain assessment
preoperative checklist
skin risk assessment
surgical or treatment consent form
time-out form
transfer form
medication administration record (MAR)
