Med-Surg121 FON Chp 7 Documentation Flashcards
Key Terms
Documentation
Auditors- examine charts for quality of care.
Chart- Health care record.
Charting- adding written info to chart.
Charting by exception (CBE)- Chart physical assessments, observations, V/S, IV site and rate and other pertinent data at the beginning of each shift.
Database- accumulated data from history, physical exams, and diagnostic test used to identify and prioritize problems.
Diagnosis-related groups (DRGs)- system classifies pts. by age, diagnosis and surgical procedure to predict length of stay and expense coverage.
Documenting- adding written info to chart.
Kardex (or Rand)- card system used to consolidate patient orders and care needs in a centralized, concise way.
Narrative charting- recording of pt. care in descriptive form.
Nomenclature- a classified system of technical or scientific names and terminology.
Key Terms
Documentation
Nursing care plan- preprinted guidelines used to care for pts. with similar health problems.
Nursing notes- nurses record of observations, care given and pts. responses.
Peer review- appraisal by professional co-
workers of equal status.
Problem list- active, inactive, potential and resolved problems, serves as index for chart documentation.
Problem-Oriented Medical record (POMR)- organized according to the scientific problem-solving system.
Quality assurance, assessment, and improvement- audit that evaluates services provided and the results achieved compared to accepted standards.
Recording- adding written info to the chart.
SOAPE- Subjective, Objective, Assessment, Plan, Evaluation
SOAPIER- Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision.
Traditional (block) chart- chart divided into sections or blocks.
Purpose of patient records
1- Written communication
2- Permanent record for accountability
3- Legal record of care
4- Research and data collection
Basic guidelines for documenting
Quality and accuracy of the nursing notes are extremely important.
RN has primary responsibility for each pts. initial admission within first 8 hours.
24 hour records
Eliminate unnecessary record keeping forms.
Easier to obtain accurate assessment info and document ADL’s
Uses flow sheets and checklists.
Ability to determine efficient staffing patterns.
Clinical (critical) pathways
Allow staff from all disciplines to develop standardized, integrated care plans for projected length of stay for patients of a specific case type.
Replaces other nursing forms such as the nursing care plan.
Long term health care documentation
Minimum Data Sets (MDS) - regulated standards for resident assessments, individualized care plans and qualifications for health care providers.
