Implementation Flashcards
What are the three skills in implementation?
Cognitive Skills (Intellectual Skills)
Interpersonal Skills
Technical Skills
What are the four cognitive skills?
Problem Solving
Decision Making
Critical Thinking
Creativity
What is the process of implementing?
Reassing the client
Determining nurse need for assistance
Implementing nurse intervention
Supervising delegated care
Documenting nursing activities
Transfer of responsibility from one person to another while retaining accountability for the outcomes
Delegation
Downward/transfer of both the responsibility and accountability of _ from one individual to another
assignment
What is the responsibility of the nurse in delegation and assignment?
Appropriate delegation of duties
Adequate supervision or assigned
Evaluation is composed of:
documenting responses to interventions
evaluating the effectiveness of interventions
evaluating outcome achievement
reviewing the nursing care plan
Measure used to maintain confidence and secure components of client records
documentation
What is essential to the goal of client care?
Effective communication among health professionals
Health personnel communicate through?
discussion
reports
records
as informal oral consideration of a subject by two or more healthcare personnel to identify a problem or establish strategies to resolve a problem.
discussion
is a formal, legal document that provides evidence of a client’s care and can be written or computer based.
record/chart/client record
The process of making an entry on a client record is called
recording, charting, or documenting.
the The Joint Commission requires client record documentation to be
A-ccurate
C-omplete
C-onfidential
T-imely
S-pecific
Health care reform has been pivotal in the process of increasing the use of the
electronic health record
states that “ ..the nurse has a duty to maintain confidentiality of all patient information”
The American Nurses Association Code of Ethics (2001)
is the rightful owner of the client record.
institution or agency
Changes in the laws regarding client privacy became effective on
April 14, 2003
HIPAA
Health Insurance Portability and Accountability Act of 1996
HIPAA
Health Insurance Portability and Accountability Act of 1996
The new HIPAA regulations maintain the privacy and confidentiality of
Protected Health Information
is identifiable health information that is transmitted or maintained in any form or medium, including verbal discussions, electronic communications with or about clients, and written communications
Protected Health Information
is identifiable health information that is transmitted or maintained in any form or medium, including verbal discussions, electronic communications with or about clients, and written communications
PHI
Security Rule of HIPAA became mandatory in
2005
This rule governs the security of electronic PHI.
Security Rule of HIPAA in 2005
What are the purpose of client’s records?
communication
planning client care
auditing health agencies
research
education
reimbursement
legal documentation
health care analysis
Communication of client’s records prevents
fragmentations
repution
delays in client care
Nurses use ________ to evaluate the effectiveness of the nursing care plan.
baseline or ongoing data
is a review of client records for quality assurance purposes
audit
Who reviews the client records to determine if a particular health agency is meeting its stated standards
The Joint Commission
The treatment plans for a number of clients with the same health problems can yield information helpful in treating other clients.
Research
For a facility to obtain payment through Medicare, the client’s clinical record must contain the
correct diagnosis related group codes
are supported by accurate, thorough recording by nurses.
codable diagnoses such as DRGs
Client’s record is ________ and is usually admissible in court as evidence
legal document
What are the different Documentation Systems?
the source-oriented record
problem-oriented Medical record
PIE model (problems, intervention, evaluation)
focus charting
CBE (Charting by exception)
Computerized documentation
Case Management
is a traditional part of the source-oriented.
Narrative Charting
Narrative recording is replaced by
Charting by exception
Focus Charting
POMR or Problem Oriented Medical Record was established by?
Lawrence Weed in 1960
the data are arranged according to the problems the client has rather than the source of the information.
POMR-Problem Oriented Medical Record
What are the advantages of POMR?
- it encourage collaboration
- the problem list in the front of the chart alerts caregivers to the client’s needs and makes it easier to track the status of each problem
all information known about the client when the client first enters the health care agency.
database
Database includes
nursing assessment
primary care provider’s history
social and family data
results of the physical examination and diagnostic test
is derived from the database.
problem list
are generated by the individual who lists the problems
care plans
is a chart entry made by all health professionals involved in a client’s care; they all use the same type of sheet for notes.
progress notes in the PO
How can you get the objective data?
IPPA
Vital Signs
Labs and diagnostic results
is the interpretation or conclusions drawn about the subjective and objective data.
Assessment
This system consists of a client care assessment flow sheet and progress notes.
Pie model
describes the patient’s perspective and focuses on documenting the patient’s current status, progress towards goals and response to interventions.
Focus Charting
provides a holistic perspective of the client and the client’s needs.
Focus charting system
Focus charting system provides
nursing process framework for progress notes
For focus charting, in the eight hours shift, use ____ for morning and afternoon shift and ____ for night shift
blue or black ink for morning and afternoon shift
red ink for night shift
What are the different nursing interventions in the focus charting?
independent
basic
perspective
is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded.
Charting by exception
Charting by exception incorporates three key elements, what are these?
Flow sheets
Standards of nursing care
Bedside Access to chart forms
is a widely used, concise method of organizing and recording data about a client, making information quickly accessible to all health professionals.
The Kardex
enables nurses to record nursing data quickly and concisely and provides an easy to-read record of the client’s condition over time,
Flow Sheet
This record typically indicates body temperature, pulse, respiratory rate, blood pressure, weight, and, in some agencies, other significant clinical data such as admission or postoperative day, bowel movements, appetite, and activity.
Graphic Record
All routes of fluid intake and all routes of fluid loss
Intake and output record
Medication flow sheets usually include designated areas for the date of the medication order, the expiration date, the medication name and dose, the frequency of administration and route, and the nurse’s signature.
Medication Administration Record
are completed when the client is being discharged and transferred to another institution or to a home setting where a visit by a community health nurse is required.
Discharge note and referral summary
