MODULE 2: DOCUMENTATION Flashcards
WHAT IS DOCUMENTATION
the process of documenting nursing information about nursing care in health records
HOW MUCH NURSING TIME IS DEDICATED TO DOCUMENTATION? (PERCENTAGE)
25%
WHAT IS THE PURPOSE OF MEDICAL RECORDS?
communication, care planning, legal record, resource management, auditing and monitoring, as well as research and education
EXPLAIN HOW MEDICAL RECORDS ARE GOOD FOR COMMUNICATION
- communication to health care team about patients needs and progress
- provides current and accurate source of information
- plan of care needs to be clear and transparent
EXPLAIN HOW MEDICAL RECORDS ARE GOOD FOR CARE PLANNING
- begins from admission with nursing history and physical assessment
- includes data, interventions, and evaluation of care
- ongoing health assessment and physical examinations documented in nursing history or separate form
EXPLAIN HOW MEDICAL RECORDS ARE GOOD AS A LEGAL RECORD
- proof of individualized goal directed care plan was offered/delivered
- reflects responses of offered, declined, or delivered care
- evidence of continued assessment, monitoring, and response to any deterioration
- timely documentation (basically chart ASAP)
EXPLAIN HOW MEDICAL RECORDS CAN BE GOOD FOR RESOURCE MANAGEMENT
- may be used to demonstrate need for and efficacy of resources (like a unit needing more nurses)
- is proof of resource allocation
EXPLAIN HOW MEDICAL RECORDS ARE GOOD FOR AUDITING AND MONITORING
- evaluates quality and appropriateness of care
- ongoing quality improvement to improve healthcare services
- deficiencies shared with healthcare team to enhance policies and practice
EXPLAIN HOW MEDICAL RECORDS ARE GOOD FOR RESEARCH AND EDUCATION
- statistical data to inform quality improvement
- morbidity and mortality
– enhance educational learning for health care students and professionals
WHAT IS AN ELECTRONIC HEALTH RECORD (EHR)
contain longitudinal record of the individuals health status including diagnostic tests, treatments, and results
WHAT IS AN ELECTRONIC MEDICAL RECORD (EMR)
Is the legal record of a single health encounter (one visit) –> it will become a part of the EHR
WHAT ARE SOME BENEFITS TO ELECTRONIC DOCUMENTATION
- increases readability, organization, and accuracy
- increases ability to make timely decisions and concurrent access to data by healthcare providers
– improvements in the quality of care
– increase in caregiver satisfaction
EXPLAIN CONFIDENTIALITY WHEN IT COMES TO CHARTING, WHY IS IT IMPORTANT?
- nurses are legally and ethically obligated to keep patient information confidential
- are responsible for protecting records from unauthorized readers
- cannot discuss with persons not involved in care
– patients have the right to have copies of medical records and read the info
WHAT ARE THE GUIDELINES FOR DOCUMENTATION AND REPORTING?
factual: descriptive, objective, avoids opinions
accurate: exact measurements, date, time, signature (agency policy will inform late enteries)
complete: with appropriate and essential information
current: is done ASAP, chronologically
organized: has logical order
compliant with standards: is set by regulatory bodies to maintain institutional accreditation and decrease liability
WHAT ARE THE CRNA STANDARDS FOR DOCUMENTATION
- accountability: for safe, competent, and ethical care through accurate, timely and factual and timely documentation
- communication and safe provision of care: make sure chart is complete, accurate, objectives, patient-centred representation of patients needs and perspectives, nurse interventions, and care outcomes
3.security: protect health information by maintaining privacy, confidentiality, in accordance with relevant registration regulations, standards of practice, and employer requirments
WHAT ARE SOME COMMON DOCUMENTATION MISTAKES
- fail to report relevant information
- fail to record nursing actions
- fail to record medication given
- recorded on the wrong chart
- fail to document discontinued medication
- fail to record reactions or changes to patients condition
- error in transcribing
WHAT ARE SOME OF THE RESULTS OF THESE COMMON MISTAKES?
Patient harm
legal liability
ethical violations
regulatory non-compliance
loss of professional credibility
financial risks
impact on healthcare team (eg. increased workload)
WHAT IS HUMAN ERROR
harm caused by a healthcare provider. documentation is required for clinical adverse events and is also sent to the RLS.
WHAT ARE SOME ESSENTIAL ELEMENTS IN CHARTING
what care was provided
who received the care
who delivered the care
when was care provided
why was care provided
patient response and outcomes to the care
WHAT ARE SOME METHODS OF DOCCUMENTATION
-narrative (like a story)
problem-oriented medical record (POMR)
- data base- assessment info
-problem list- identified needs
- care plan- by discipline
progress notes (SOAP, SOAPIE, PIE, DARP)
WHAT DOES DARP STAND FOR
data (subjective and objective), action (nursing interventions), response (how patient responded to intervention), plan (follow-up and adjustments)
WHEN WOULD WE USE FOCUS CHARTING?
- gathering patient data
- addressing specific patient issue
- documenting interventions
- evaluating patient response to treatment
- conducting patient education
- communicating changes in care
- addressing critical incidents or emergencies
