Informatics and documentation Flashcards
Documentation
Key communication strategy that produces a written account of important patient patient data, clinical decisions, interventions and patient responses in a health record.
Documentation consists of…
all information entered into a health record
Information in health record
provides quality of care delivered
Documentation provides 4
The quality of care
the standards of regulatory agencies and practices
the reimbursement structure
Legal guidelines
Medicaid medicare
CMS
The information that a nurse enters into a health record communicates
Type and frequency of care delivered
provides accountability for care implemented
Patient documentation in health record must include
and this allows
Assessment data, nursing problems or diagnosis, interventions, evaluations
Providers to track patients clinical course
Purpose of a health care record
Facilitating interprofessional communication
legal record of care
justification of financial billing.
Reimbursement of care
Data from documentation is used to
audit
monitor
evaluate
educate
When not documented well risks
tasks are repeated, omitted, or delayed
Mistakes in documentation that lead to malpractice
Failing to record information health of drug record nursing actions record medication admin record drug allergies record complete information record discontinued medication
Charting
Document right away
use flow chart
charting by exception
Guidelines for quality documentation
stick to the facts
write in short sentences
use simple short words
avoid jargon and abbreviations
Quality documentation has 5 characteristics
factual, accurate, current, organized, complete
Nurses responsibilities
what medications do and what labs mean
