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
