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
Purpose of medical record 8
communication legal documentation reimbursement auditing and monitoring evaluating patient outcomes research and education
EHR
Electronic Health record
Started in 2009
2017 - 93-99 of all hospitals certified technology had IT
HIPAA
Health Insurance Portability and Accountability Act
Privacy rule-requires disclosure or requests are limited to specific information for particular purpose
Notify patients of privacy policies- obtain written acknowledgment from patients indicating they received info
Security Rule- Admin, security. technical. safeguards that protect patient info.
Guidelines for charting
Factual- Accurate Complete Current Organized complete
Charting current
vitals, pain, admin meds, treatment, prep for diagnostic, change in status, change in location (death). response to treatment.
Do not use abbreviations
U for unit IU for internal unit trailing 0 lacking leading zero MS, MS04- morphine, solfate magnesium, solfate
Methods of documentation
Narrative
Charting by exception
SBAR
SBAR
Situation, background, assessment, recommendation
Telephone and verbal orders
included in notes
and what to do
discouraged unless emergent
write down notes
read back and chart that it was read back
document right away.
Time-phone number-who made the call- who took the call- who the information was given to what the information was, what was received back
