Quiz 2 documentation powerpoint Flashcards
Paper record
Episode-oriented
Key information may be lost from one episode of care to the next.
Electronic health record (EHR)
A digital version of a patient’s medical record
Integrates all of a patient’s information in one record
Improves continuity of care
Narrative
story-like format. Weaknesses of the narrative format include repetition, length, and disorganization
Problem-oriented medical record (POMR)
organized according to the patient’s health care problems. Data are organized by problem or diagnosis. Database Problem list Care plan Progress notes
SOAP
Subjective, objective, assessment, plan
SOAPIE
Subjective, objective, assessment, plan, intervention, evaluation
PIE
Problem, intervention, evaluation
PIE charting has no separate care plan. The plan of care is incorporated into the progress notes. Patient problems are documented and numbered and addressed by that number in the progress notes.
Focus charting (DAR)
Data, action, response
incorporates not only medical and nursing diagnoses but patient concerns and behavior, therapies, and responses.
Charting by exception—CBE
Only deviations from the well-defined standards of practice are documented. Decrease in charting time and emphasis on significant data are benefits.
Source records
A separate section for each discipline
separated into nursing, medicine, social work, and respiratory therapy. The advantage is that caregivers can locate each section in which to document entries. The disadvantage is that patients’ problems are distributed across the record, and the record does not show how information is related and care is coordinated to meet patients’ needs.
Case management plan and critical pathways
incorporates an interdisciplinary approach to documenting patient care. Critical pathways are interdisciplinary care plans that include patient problems, key interventions, and expected outcomes within an established time frame.
•Unexpected outcomes, unmet goals, and interventions not specified within the critical pathway time frame are called variances.
Critical Pathways
Multidisciplinary approach to document client care
Standardized POC summarized into pathways with a case management plan
1-2 page integrated care plan for problems
Key interventions + expected outcomes
Admission nursing history form
Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems
Flow sheets and graphic records
Help team members quickly see patient trends over time and decrease time spent on writing narrative notes
Patient care summary or Kardex
Many hospitals now have computerized syThe summary automatically updates as nurses stems that provide information in the form of a patient care summary that is often printed for each patient during each shift. make decisions, and data (e.g., orders) are entered into the computer.
•In some settings, a Kardex is kept at the nurses’ station. An updated Kardex eliminates the need for repeated referral to the chart for routine information throughout the day.
Standardized care plans
Preprinted, established guidelines used to care for patients who have similar health problems
Discharge summary forms
includes medications, diet, community resources, follow-up care, and whom to contact in case of an emergency or for questions
Acuity records
not part of a patient’s medical record. They are used for determining the hours of care and the staff required for a given group of patients
What to document
Your interventions w/ patient’s response and your evaluation Any significant changes or events in condition Informed consent Patient teaching Any attempts to contact medical staff Patient leaving AMA Patient’s refusal of treatment Spiritual concerns Use of restraints Medication Administration
Hand-off report
Occurs with transfer of patient care
Provides continuity and individualized care
Reports are quick and efficient.
Home Care Documentation
Documentation in the home care system is different from that in other areas of nursing.
•Some parts of the record remain in the home with the patient; other information is needed in an office setting. Thus duplication of documentation is often necessary. Agency policies indicate which forms nurses need to leave at their office versus which forms must be taken into the homes.
•Evolving computerized patient records are making it easier for records to be available in multiple locations.
Long-Term Health Care Documentation
Long-term care documentation is interdisciplinary and is closely linked with fiscal requirements of outside agencies.
Increasing numbers of older adults and people with disabilities in the United States require care in long-term health care facilities.
•The goal is a system of clinical documentation that improves care for residents and increases reimbursement for that care.
The Omnibus Budget Reconciliation Act of 1987 includes Medicare and Medicaid legislation for long-term care documentation.
Telephone reports and orders
Situation-background-assessment-recommendation (SBAR)
Document every call
Read back
Incident or occurrence reports
Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient
Follow agency policy
Critical elements in an incident or occurrence report
Date/time of occurrence How nurse found the client Witness info Assessment of client’s injury Actions taken + FU notations Who finds/witnesses the incident writes the report Not part of the medical record
Examples of incidents
patient falls, needlestick injuries, a visitor having symptoms of illness, medication administration errors, accidental omission of ordered therapies, and circumstances that lead to injury or to risk for patient injury.
Health care information system (HIS):
a group of systems used in a health care organization to support and enhance health care
consists of two major types of systems: clinical information systems (CISs) and administrative information systems. Together the two systems operate to make the entry and communication of data and information more efficient.
patient identifiers
birth date, social security number, room number, or medical record number.
Purposes of Records
communication research client education legal documentation financial billing/ reimbursement auditing/monitoring
Quality Guidelines for recording
Factual Accurate Complete Current Organized Nonjudgmental Timely Concise
Legal Guidelines for recording
Correct all errors promptly, using the correct method.
Record all facts
Do not leave blank spaces
Write legibly in permanent black ink.
If an order was questioned, record that clarification was sought.
Chart only for yourself, not for others.
Avoid generalizations.
Begin each entry with the date/time and end with your signature and title.
Keep your computer password secure.
