UNIT 3: Documentation; Introduction to medical terminology Flashcards
Documentation:
The process of documenting nursing info about nursing care in health records.
Uses and purposes of Medical Records:
Communication/Care Planning
Legal Documentation
Funding/Resource Management
Auditing & Monitoring
Research
Education
Types of Records:
Electronic health record
Source-oriented record
Problem-oriented record
Ways to document nursing care:
Narrative
SOAP[IE]
PIE
Focus Charting (DAR)
Chart by Exception
Case Management
Electronic Health Record (EHR):
Refers to a longitudinal (lifetime) record of all healthcare encounters for an individual.
Electronic Medical Record (EMR):
Refers to the legal record that describes a single encounter/visit by a patient to a hospital or out-patient healthcare setting.
(the source of data for the EHR)
Problem-oriented Healthcare/Medical Records (POMR):
A system for organizing documentation that places the primary focus on the Pts individual problems. POMR has 4 major sections:
- Database
- Problem List
- Care Plan
- Progress Notes
POMR: Database
Contains all available assessment info pertaining to the patient. the database provides the foundation for identifying Pt problems and planning care.
- Includes: medical history; physical assessment; nursing admission history; ongoing assessment; lab reports; + test results
POMR: Problem List
Includes a patients physiological, psychological, social, cultural, spiritual, developmental, and environmental needs.
POMR: Care Plan
Team members from each discipline that are involved in a Pt’s care develop a care plan for each problem (ADPIE)
POMR: Progress Notes
Where healthcare members monitor and record a Pt’s progress. There are many formats of progress notes:
1) SOAP
2) SOAPIE
3) PIE
4) DAR
Source-oriented Record:
A traditional “chart”
Where the patients chart is organized so that each discipline has their own section to record data. There are many components/sections of a source record (9 main ones)
9 Main Sections/Components of a Source Record:
Admission sheet
Nurse’s admission sheet
Medical history & exam
Progress notes
Discharge summary
Order sheet
Graphic/flow chart
Medication administration record (MAR)
Healthcare disciplines records
Ways to document nursing care: Narrative Charting
The method traditionally used to record patient assessment and the nursing care provided. This method documents info in a simple, story-like format
Ways to document nursing care: SOAP
Can only really be used for a singular condition and stands for:
Subjective-Objective-Assessment-Plan
Ways to document nursing care: SOAPIE
Same as soap but with intervention and evaluation added on:
Subjective-Objective-Assessment-Plan-Intervention-Evaluation
Ways to document nursing care: PIE
Was created with nurses and nursing care in mind. PIE stands for:
Problem-Intervention-Evaluation
*There is no assessment done in PIE, it is done separately.
Ways to document nursing care: DAR (Focus Charting)
DAR, a.k.a. Focus Charting is the most patient-centred form of documentation. It is based on the patient’s concerns. DAR stands for:
Data (objective & subjective)-Action (interventions)-Response (evaluation/Pt’s response)
Ways to document nursing care: Charting by Exception (CBE)
Based on the idea that a Pt meets all standards unless otherwise documented. this system incorporates standards of care, evidence-informed interventions, and clearly defined criteria for/of “normal” findings
Within Defined Limits (WDL)/Within Normal Limits (WNL):
Pre-defined definitions or statements that consists of written criteria for a “normal” assessment for each body system.
Ways to document nursing care: Case Management and use of Critical Pathways
- The case management model incorporates an interdisciplinary approach to documenting Pt care.
- Critical pathways are standardized plans of care for a specific disease/condition (there can be variance)
Variance:
When the activities on the critical pathway are not completed as predicted or patient does not meet the expected outcomes.
Common Record Keeping forms: (7 types)
1) Admission Database
2) Standardized Care Plan
3) Kardex (temporary record)
4) Flowsheets/Graphic Record
5) Progress Notes
6) Discharge Summary
7) Incident/Work Safety Reports
Common Record Keeping forms: Admission Database
Completed when a Pt is admitted to a nursing care unit. Data on history forms provide baselines that can be compared with changes in the Pt’s condition
Common Record Keeping forms: Standardized Care Plan
Plans based on the institutions of nursing practice that are pre-printed, established guidelines that are used to care for Pt’s who have similar health problems
Common Record Keeping forms: Kardex (temporary record)
Provides basic summative info and can be continually updated. it provides the nurse with a list of orders, treatments, + diagnostic testing.
Info commonly found on the Pt care summary or Kardex includes:
Basic demographic data
Hospital ID#
Medical + Surgical history
Physicians name
Primary Medical Diagnosis
Current Prescriptions
Nursing care plan
Nursing orders
Allergies
Contact Info
Emergency Code Status
Common Record Keeping forms: Flowsheets/Graphic Records
Used to document physiological data and routine care. These allow the nurse to quickly & easily enter assessment data a/b a Pt, such as vital signs, admission + daily weights.
Common Record Keeping forms: Progress Notes
Specific to nurses
Where nurses write their narrative documentation.
Common Record Keeping forms: Discharge Summary
Helps ensure a Pt leaves the hospital in a timely manner with the necessary resources in place. Discharge planning normally begins at admission.
Common Record Keeping forms: Incident/Work Safety Reports
For unusual occurrences for:
- Involved in or witness
- Near-miss/Errors
- No Blame (don’t ever place blame on others)
The 6 Characteristics/Guidelines of Quality Documenting:
Factual
Accurate
Complete
Current
Organized
Compliant with Standards
Timely
Sign ALL Entries
3 Types of Medical Terms:
1) Latin and Greek Word Parts
2) Eponyms
3) Modern English Words
Parts of Latin + Greek Based Words:
Word Roots
Suffixes
Prefixes
Combining Vowels
Eponyms:
Terms based on a person’s name
Word Roots:
Gives the essential meaning of the term. Normally (but not always) refers to a body structure, organ, or system.
Suffixes:
Found at the end of the medical term and provides info on conditions, diseases, surgical + diagnostic procedures.
Prefixes:
Found at the beginning of the medical term and provides info on abnormal conditions, #s, positions, and times.
Combining Vowels:
Used to connect words and make medical terms easier to say by placing a vowel between a root and a suffix or between 2 word roots (usually an o)
