Informatics & Documentation Flashcards
why is DOCUMENTATION so important?
this is the way of COMMUNICATION in nursing; allows proper standards and decreases risk of errors
- ensures that CARE has been done, and investigates the QUALITY of care
functions and purpose of a HEALTH CARE RECORD
- helps to organize COMMUNICATION between HCP/prevents duplication
- LEGAL RECORD OF CARE; is the most current source of the patient
- REIMBURSEMENT of CARE
- MONITORING/AUDITING of CARE
- EDUCATION/EBP/RESEARCH
HITECH
the HEALTH INFORMATION TECH for ECONOMIC and CLINICAL HEALTH ACT
- helps to improve quality and value of healthcare by ensuring patient info is all in one record
what is the NURSES responsibility?
must keep all INFORMATION CONFIDENTIAL
- only discuss with healthcare team members
- PHI - protected health information
what are some breaches in confidentiality?
ex. displaying patient info on screen
ex. conversations being overheard
ex. sharing printers
ex. not properly discarding copies of patient info
how are HEALTH RECORDS PROTECTED?
- use of physical & local restrictions
- restricted area access/privacy filters
- timestamping of the charts
- passwords
how do we DISPOSE INFORMATION?
anything printed or written down has to be DESTROYED/SHREDDER
- must DE-IDENTIFY ALL PATIENT DATA
- use of COVER SHEETS/VERIFICATION before sending fax
what are the GUIDELINES for QUALITY DOCUMENTATION? (5)
- FACTUAL
- ACCURATE
- CURRENT
- ORGANIZED
- COMPLETE
*use of military time/documenting in real time
what are the METHODS of DOCUMENTATION?
- FLOW SHEETS
looking at specific body systems - PROGRESS NOTES
using a narrative form of charting/often has templates - CHARTING by EXCEPTION
referring to something that is deviating from NORMAL
ex. WNL/WDL - within normal/defined limits
PIE charting
P - PROBLEM
(diagnosis of pt.)
I - INTERVENTION
E - EVALUATION
SOAP charting
S - subjective
O - objective
A - Assessment
(patient diagnosis, patient progress etc…)
P - planning
patient care summary
document to help for
report; basic info needed
for the patient; understand patient needs, name, care plan, treatments, schedule
discharge summary forms
if patient is having follow up care or leaving
to another hospital
- starts at ADMISSION
how do we DOCUMENT or TAKE VERBAL ORDERS/TELEPHONE ORDERS?
*often discouraged due to HIGH ROOM OF ERROR
- must ALWAYS READ BACK ORDER to HCP
- always DOCUMENT EVERY PHONE CALL made to the HCP
- document time, date and content of the call
incidence/occurrence reports
is any event that is not
consistent with the routine, expected care of a patient or the standard procedures in place on a health care unit or within an agency.
- ensuring proper quality improvement
