Module 8 - Documentation - Start of Final Exam Flashcards

1
Q

Why is having the patient verbalize understanding improtant?

A

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

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2
Q

Documentation

A

the written or electronic legal records of all pertinent interaction with the patient

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3
Q

Patient Records

A

complete record of health information

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4
Q

Purpose of Patient Records

A
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
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5
Q

5 Elements of Documentation

A

Content

timing

format

accountability

confidentiality

on page 459 know the terms**

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6
Q

dont document until…

A

AFTER something is done

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7
Q

Characteristics of Effective Documentation

A
Consistent with professional and agency standards
Complete
Accurate
Concise
Factual
Organized and timely
Legally prudent
Confidential
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8
Q

Important DO NOT USE List Parts

A

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

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9
Q

What is Confidentiality?

A

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

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10
Q

Potential Breaches in Patient confidentiality

A

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

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11
Q

Patient Rights

A
  1. See a copy of their health records
  2. Update their health records
  3. Get a list of disclosures
  4. Request a restriction on certain use of disclosures
  5. Choose how to receive health information
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12
Q

The only time you can receive verbal orders is during an …

A

emergency (otherwise it must be written or electronic)

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13
Q

Policy for Receiving Verbal Orders in an Emergency

A

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

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14
Q

Policy for Physician Or Nurse Practitioner Review of Verbal Orders

A

Review orders for accuracy

Sign orders with name, title, and page number

Date and note time orders signed

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15
Q

Duties for RN Receiving Telephone Orders

A

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)

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16
Q

Purpose of Recording Data

A

Facilitate quality, evidence-based patient care

Serve as a financial and legal record

Help in clinical research

Support decision analysis

17
Q

t.o.

A

telephone order

18
Q

2 Types of Personal health Records

A
  1. Standalone Personal health records

2. tethered/connected personal health records

19
Q

Standalone Personal Health records

A

patients fill in information from their own records; the information is stored on patients’ computers or the internet

20
Q

Tethered / Connected Personal health Records

A

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

21
Q

Benefits of health Information Exchange

A

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

22
Q

Methods of Documentation

A

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)

23
Q

5 Major components of problem oriented medical records

A
  1. Defined Database
  2. Problem List
  3. Care plans
  4. progress notes
  5. soap format
    * this is organized around their proble
24
Q

Advantage of Problem Oriented Medical Record

A

entire team makes a master list of problems and contributes collaboratively and focuses in on the problem

25
Q

SOAP Format

A

Subjective Objective Assessment Plan

26
Q

Format for Nursing documentation

A

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

27
Q

Types of Flow Sheets

A

Graphic records

24-hour fluid balance record

Medication administration record (MAR)

24-hour patient care record

Acuity records

28
Q

4 Medicare Requirements for home health care

A
  1. Patient is homebound and still needs skilled nursing care
  2. Rehabilitation potential is good (or patient is dying)
  3. The patient’s status is not stabilized
  4. The patient is making progress in expected outcomes of care
29
Q

4 Basic components of RAI (Resident Assessment tool)

A
  1. minimum data set
  2. triggers
  3. resident assessment protocols
  4. utilization guidelines
30
Q

RAI

A

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

31
Q

Benefits of RAI

A

Residents respond to individualized care

Staff communication becomes more effective resident and family involvement increases

Documentation becomes clearer

32
Q

Hand off communication in the hospital

A

ISBARR

33
Q

ISBARR

A

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

34
Q

Change of Shift / Hand Off Reports

A

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

35
Q

During a change of shift report what happpens?

A

The info is given in ISBARR format while the new nurse writes it down

36
Q

Telephone/Telemedicine Reports: Information to Know

A

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

37
Q

Conferring About Care

A

Consultations and referrals

Nursing and interdisciplinary team care conferences

Nursing care rounds

Purposeful rounding

38
Q

Purposeful Rounding

A

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

39
Q

8 Behaviors of Purposeful Rounding

A

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