OTHER SOURCES OF CLIENT Flashcards
it is a medical info held about an individual patient. It includes info related to their past and current health or illness, their treatment history, lifestyle choices and genetic data
Clients data
data obtained from the patient herself
Primary Source
data include info from the patient’s chart, fam mem, or other health care team members.
Secondary sources
is a complete and total record of a patient’s clinical data and medical history
Clients chart
“Requires client record to be timely, complete, accurate, confidential and specific to the client.”
Jcaho
“ . . . the nurse has a duty to maintain confidentiality of all patient information.”
ANA (American Nurses Association) code of ethics
“Accurate documentation of actions and outcomes of delivered care is the hallmark of nursing accountability.”
Code of ethics for filipino nurses
is a federal law that requires the creation of
national standards to protect sensitive patient health information from being disclosed.
Health Insurance Portability and Accountability Act of 1996
to provide continuity of care which means documenting services, so others have a source upon which to base care.
PRIMARY PURPOSE OF CLIENT RECORDS
Prevents fragmentation, repetition and delays in client care as it is used by health care professionals in communicated with each other and with the client.
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Communication
Review client records for quality assurance to determine if the hospital is meeting its stated standards.
Auditing Health Agencies
Data in the record can be used for nursing research. Treatment plans for several clients with the same health problems can yield information helpful in treating other clients.
Research
Client records may use data as educational tools.
Education
Client’s records serve as evidence in court. Admissible in court as evidence unless client objects
because information client gives to primary care provider is confidential.
Legal Document
Records may help health care planners identify agency needs, such as overuse or underuse of
hospital services.
Health Care Analysis
What are the key elements of a client’s medical chart
• Patient Demographics
• Financial Info
• Consent and authorization forms
• Medical History
• Nursing Records
• Diagnostic Procedures and lab results
• Operative and Anesthesiology Report
• Discharge Summary
• Assignment of benefits: the patient or guarantor authorizes their health insurance company to make payments directly to the physician, medical practice, or hospital for the treatment received.
Financial Information
Filled out by the patient on their first visit to the doctor’s office and updated as needed.
It contains information that is directly related to the patient, such as their last name, first name, gender, DOB, marital status, address, telephone number, employment status, employer’s address and phone number, and
name and contact information for the person who is responsible for them.
Patient Demographics
it is a signed statement from the patient or guardian approving the course of treatment.
Consent and Authorization Forms
This document outlines any medical ailments the patient has had in the past and present.
Medical History
In these records, vital indicators including blood pressure, temperature, pulse, respiration, intake, output, etc of the patient are recorded.
Nursing Records
include new information and changes during patient treatment.
Progress Notes
Prescribed medication including dose, method of intake, and schedule.
Medication List
These comprise documents containing the findings of every diagnostic test and laboratory procedure that the patient underwent.
Diagnostic Procedures and Lab results
Surgeon’s written account of the process, including the preoperative and postoperative diagnoses, the precise specifics of the surgical procedure, the patient’s response to it, and any complications that may have arisen
Operative and Anesthesiology Report
A summary of the patient’s hospital care, including the date of admission, the diagnosis, the course of treatment and any responses from the patient, the outcomes of the tests, the final diagnosis, the follow-up plans, and the date of discharge.
Discharge Summary
Physician’sordersforthepatienttoreceivetesting,procedures,orsurgeryincludingdirectionstoother
treatment team members.
Doctors Order Sheet
What is the 2 nurses responsibility?
• Ensure that records are accurate and complete to effectively manage the client and allow for good communication between the nurse and other healthcare members.
• Keeping good nursing records allows for identifying problems that have arisen and the action is taken to rectify them.
A variety of paper or electronic forms are available for the type of information nurses routinely document.
Common Record Keeping forms
a nursing history form when a patient is admitted to a nursing unit.
The form guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems.
Admission Nursing Forms
allow you to quickly and easily enter assessment data about a patient. It helps team members quickly see patient trends over time and decrease time spent on writing narrative
notes.
Flow Sheets and Graphic Records
• Concise method of organizing and recording data
• Series of cards kept in a portable index file or on computer-generated form.
• Information quickly accessible
• Pertinent information about the client arranged in sections.
Kardex
• Made by nurses.
• Provide information about the progress a client is making toward achieving desired outcomes.
• Include information about client problems and nursing interventions.
Nurses Progress Notes
• Completed when client discharged - terms that can be readily understood.
• Completed when client transferred to another institution.
• Include some or all the following: Description of client’s physical, mental, and emotional status, resolved health
problems, Treatments to be continued, Current medications, include restrictions that relate to activity, diet, and bathing, Functional/self-care abilities, Comfort level, Support networks, Client education, Discharge destination, Referral services.
Discharge Summary Form
REMEMBER
“What is not written, is not done”
