information technology Flashcards
The Joint Commission (formerly JCAHO)
mandates the use of computerized databases to expedite the accreditation procesproceproces
Subjective data
information obtained from the patient perspective
Objective data
information the nurse obtains through assessment of the patient
Accurate and concise documentation
Document facts and information precisely (what the nurse sees, hears, feels, smells) without any interpretations of the situation
Complete and current documentation
- Never pre-chart an assessment, intervention, or evaluation
- Timely documentation occurs as soon after the observation or event as possible
Flow charts
show trends in vital signs, blood glucose levels, pain level, and other frequent assessments
Narrative documentation
records information as a sequence of events in a story-like manner
Charting by exception
uses standardized forms that identify norms and allows selective documentation of deviations from those norms.
Problem-oriented medical records
organized by problem or diagnosis and consist of a database, problem list, care plan, and progress notes. Examples include SOAP, PIE, and DAR.
SOAP
S Subjective data
O Objective data
A Assessment for diagnosis
P Plan
PIE
P Problem
I Intervention
E Evaluation
DAR
focus charting
D Data
A Action
R Response
Change-of-shift report formats:
face-to-face, audiotaping, or presentation
HIPAA Privacy Rule
requires that nurses protect all written and verbal communication about clients
