NUR 101 Exam 3 Documenting and informatics Flashcards
What are some of the reasons for documenting and informatics
for legal purposes
for communicating
for patient records
prevent errors -learn from the previous persons mistakes.
if you give oral meds for pain when should the nurse assess and do her documentation?
1 hour later
If it was not documented we can assume that the nurse…..?
did not get it done!
if you give IV meds for pain when should the nurse go back to assess the patient and document?
1/2 hour later
Every single intervention must have documentation so that we can make changes or keep things the same.
know this!
Interdisciplinary communication with in the health care team can be done in 5 ways
records or charts - confidential permanent legal document.
Reports - oral, written, or auto taped exchange of information
conferences - team members communicating in a group.
consultations - professional caregivers giving formal advice to another caregiver
referrals- arrangement for services by another care provider
Information regarding a patient’s health status may not be released to non-health care team members because?
legal and ethical obligations require health care providers to keep information strictly confidential.
If you make a mistake on a written documentation what do you do to correct it?
put a single line through it with the word error with your initials. never scribble over what you wrote.
what are the purposes of records?
communication
medicaid and medicare reimbursement, education, legal documents, research and auditing/monitoring - to make sure standards are always being met.
legal guidelines for recording
Correct all errors promptly using a line
Record all facts - no personal opinions
Do not leave blank spaces
Write legibly in permanent black ink
If an order was questioned, record clarification was sought.
Chart only for your self not others what you did on your time.
Avoid generalizations
Begin each entry with date/time and end with signature and title
keep your computer password secure
guidelines for quality documentation and reporting
factual accurate complete current organized the new order always supersedes the old order
problem-oriented medical record
(POMR) is a method of recording it consists of:
database
problem list
care plan
progress notes
the traditional method of recording is?
Narrative
What is an electric health record (EHR)?
A digital version of a patient’s medical record
Integrates all of a patient’s information in one record.
Improves quality of care
SOAP notes/ progress notes
subjective
objective
assessment
plan
