Module 8 - Documentation - Start of Final Exam Flashcards
Why is having the patient verbalize understanding improtant?
To document appropriately so when presented to others it is understood, and also incase the charting has to go to court - then that info needs to be actual and to the point
Documentation
the written or electronic legal records of all pertinent interaction with the patient
Patient Records
complete record of health information
Purpose of Patient Records
Communication Diagnostic and therapeutic orders Care planning Quality process and performance improvement Research; decision analysis Education Credentialing, regulation, and legislation Reimbursement Legal and historical documentation
5 Elements of Documentation
Content
timing
format
accountability
confidentiality
on page 459 know the terms**
dont document until…
AFTER something is done
Characteristics of Effective Documentation
Consistent with professional and agency standards Complete Accurate Concise Factual Organized and timely Legally prudent Confidential
Important DO NOT USE List Parts
U, u (for unit) –> use the word unit
IU (International Unit) –> spell it out
QD Q.D q.d. qd (Daily) –> write daily
QOD Q.O.D. q.o.d qod (every other day) –> write every other day
trailing zeroes –> write X mg
lack of leading zero –> write 0.X mg
MS –> write morphine sulfate or magnesium sulfate
MSO4 and MgSO4 –> write out since they are confused for one another
What is Confidentiality?
All information about patients written on paper, spoken aloud, saved on a computer
ex:
Name, address, phone, fax, social security number
Reason the person is sick
Treatments patient receives
`
Information about past health conditions
Potential Breaches in Patient confidentiality
Displaying information on a public screen
Sending confidential email messages via public networks
Sharing printers among units with differing functions
Discard copies of patient information in trash cans
Holding conversations that can be overheard
Faxing confidential forms to unauthorized persons
sending confidential messages over heard on pagers
Patient Rights
- See a copy of their health records
- Update their health records
- Get a list of disclosures
- Request a restriction on certain use of disclosures
- Choose how to receive health information
The only time you can receive verbal orders is during an …
emergency (otherwise it must be written or electronic)
Policy for Receiving Verbal Orders in an Emergency
Record the orders in patient’s medical records
Read back the order to verify accuracy
Date and note the time orders were issued in emergency
Record verbal order and name of the physician issuing the order, followed by nurse’s name and initials
Policy for Physician Or Nurse Practitioner Review of Verbal Orders
Review orders for accuracy
Sign orders with name, title, and page number
Date and note time orders signed
Duties for RN Receiving Telephone Orders
Record the orders in patient’s medical records
Read order back to practitioner to verify accuracy
Date and note the time orders were issued
Record telephone orders, and full name and title of
physician or nurse practitioner who issued the orders
Sign the order with name and title provider and then a slash with the nurse who is taking the order off (physician name and your name and title)
Purpose of Recording Data
Facilitate quality, evidence-based patient care
Serve as a financial and legal record
Help in clinical research
Support decision analysis
t.o.
telephone order
2 Types of Personal health Records
- Standalone Personal health records
2. tethered/connected personal health records
Standalone Personal Health records
patients fill in information from their own records; the information is stored on patients’ computers or the internet
Tethered / Connected Personal health Records
linked to a specific health care organization’s electronic health record (EHR) system or to a health plan’s information system
used more often now where patients can update via a link
Benefits of health Information Exchange
Provides a vehicle for improving quality and safety of patient care
Provides a basic level of interoperability among EHRs maintained by individual physicians and organizations
Stimulates consumer education and patients’ involvement in their own health care
Helps public health officials meet their commitment to the community
Creates a potential look for feedback between health-related research and actual practice
Facilitates efficient deployment of emerging technology and help care services
Provides the backbone of technical infrastructure for leverage by national and state-level initiatives
Methods of Documentation
Source-oriented records
Problem-oriented medical records
PIE charting (problem, intervention, evaluation
Focus charting
Charting by exception
Case management model
Computerized documentation/Electronic health records (EHRs)
5 Major components of problem oriented medical records
- Defined Database
- Problem List
- Care plans
- progress notes
- soap format
* this is organized around their proble
Advantage of Problem Oriented Medical Record
entire team makes a master list of problems and contributes collaboratively and focuses in on the problem
SOAP Format
Subjective Objective Assessment Plan
Format for Nursing documentation
Initial nursing assessment
Care plan; patient care summary
Critical collaborative pathways
Progress notes
Flow sheets and graphic records
Medication records
Acuity records
Discharge and transfer summary
Long-term care and home health care documentation
Types of Flow Sheets
Graphic records
24-hour fluid balance record
Medication administration record (MAR)
24-hour patient care record
Acuity records
4 Medicare Requirements for home health care
- Patient is homebound and still needs skilled nursing care
- Rehabilitation potential is good (or patient is dying)
- The patient’s status is not stabilized
- The patient is making progress in expected outcomes of care
4 Basic components of RAI (Resident Assessment tool)
- minimum data set
- triggers
- resident assessment protocols
- utilization guidelines
RAI
Resident Assessment Tool
document for long term care which helps staff gain definitive information on a patients strengths and needs, allows for making an individualized care plan, help achieve and ID goals and make modifications
it helps the resident get the highest care and health possible and maintain individuality (also a part of QOC)
basically - its a document that helps facility to get paid for services and also helps ID what the patients strengths, weaknesses, and what they are capable of doing
Benefits of RAI
Residents respond to individualized care
Staff communication becomes more effective resident and family involvement increases
Documentation becomes clearer
Hand off communication in the hospital
ISBARR
ISBARR
Identity / Introduction (who you are, why, where you are)
Situation (why is this hand off occurring to another unit)
Background (what led to this situation)
recommendation (what you would do to correct the issue)
Readback of roders/Response
Change of Shift / Hand Off Reports
Info given from primary nurse to another:
Basic identifying information about each patient:
name, room number, bed, designation, diagnosis, and attending and consulting physicians
Current appraisal of each patient’s health status
Current orders (especially any newly changed orders)
Abnormal occurrences during the shift
Any unfilled orders that need to be continued onto the next shift
Patient/family question, concerns, needs
Report on transfers/discharge
During a change of shift report what happpens?
The info is given in ISBARR format while the new nurse writes it down
Telephone/Telemedicine Reports: Information to Know
Identify yourself and the patient, and state your relationship to the patient
Report concisely and accurately the change in the patient’s condition that is of concern and what has already been done in response to this condition
Report the patient’s current vital signs and clinical manifestations
Have the patient’s record at hand to make knowledgeable responses to any physician
Concisely record time and date of the call, what was communicated, and physician’s response
Conferring About Care
Consultations and referrals
Nursing and interdisciplinary team care conferences
Nursing care rounds
Purposeful rounding
Purposeful Rounding
Nurse EBP where the nurse goes room to room and gives information on each patient while involving them to reduce issues and increase patient satisfaction
8 Behaviors of Purposeful Rounding
Use open key words (C-I-CARE) with PRESENCE
Accomplish scheduled tasks
Address four Ps
Address additional personal needs, questions
Conduct environmental assessment
Ask “is there anything else I can do for you? I have time”
Tell the patient when you will be back
Document the round
