W1FI MOD5- DOCUMENTATION Flashcards
-Is the written or typed, legal record of all pertinent interactions with the patient.
- It is a nursing action that produces a written account of pertinent patient data,
nursing clinical decisions, and interventions and patient responses in a health
record. - It is a vital aspect of nursing practice.
DOCUMENTATION
Accurate documentation is one of the best defenses for legal claims associated with nursing care.
LEGAL DOCUMENTATION:
Who are involved in documentation
HEALTH CARE TEAM- it is valuable sources of data,
where is the documentation entered into?
MEDICAL RECORD
aside from legal record, data collection, and a valuable source for all health care members what else can documentation be used for?
RESEARCH DATA
Is one way that members of the health care team communicate about patient’s needs and responses to care, clinical decision making, individual therapies, content of consultations, patient education and discharge planning.
COMMUNICATION
Accurate documentation is one of the best defenses for legal claims associated with nursing care
LEGAL DOCUMENTATION
Insurance companies used the record to determine payment and reimbursement
. Reimbursement
: Researchers might study patient records, hoping to learn how best to recognize or treat identified health problem from the study of similar cases
Research
To determine the degree to which standards of care are met and identify areas needing improvement and staff development
Auditing and Monitoring
Health care professional and students reading a patient’s chart can learn about the clinical manifestations of particular health problems, effective treatment modalities, and factors that affect patient goal achievements.
Education
list some mistakes in documentation that commonly result in malpractice
Failing to record pertinent health or drug information
Failing to record nursing actions
Failing to record medication administration
Failing to record drug reactions or changes in patient’s condition
Incomplete or illegible record
Failing to document discontinued medication
T OR F: avoid words like “good”, “average”, or “sufficient”; other generalizations “seems comfortable”
T
T OR F: record your interpretation of patient findings
F- record observations
- chart in a timely manner
- indicate date and time
- document ass closely as possible to the time of their execution
TIMING
T OR F: NEVER document interventions before carrying them out
TRUE
most documentation follow this type of time
MILITARY CLOCK TIME
what are some format guidelines?
- correct chart before writing
- chart on the proper form as designated by agency policy
- print or write legibly in dark ink (use correct grammar and spelling, standard terminology, follow computer documentation guidelines)
- date and time each entry
- NEVER skip lines. draw a single line through blank spaces
- chart chronologically
signing after each entry is which part of guidelines
ACCOUNTABILITY
-sign first initial, last name and title to each entry
ACCCOUNTABILITY
T OR F: use dittos, erasures or correcting fluids when an entry mistake is made
FALSE: draw a single line, use words “mistaken entry or error in charting”. re-write the entry correctly
- patient have a moral and legal right to privacy
CONFIDENTIALITY
T OR F: actual patient names and other identifiers should not be used in reports
TRUE
- Is a method traditionally used to record patient assessment and nursing care provided.
- It is simply the use of a story like format to document information.
NARRATIVE DOCUMENTATION
this type of documentation is consuming and repetitious. It requires the reader to see through a lot of information to locate desires data
NARRATIVE DOCUMENTATION
Each person or department makes notations in a separate section/s of the client’s chart.
Source-Oriented Medical Record (Traditional client record)
what are the five basic component of the traditional client record
ADMISSION SHEET PHYSICIAN’S ORDER SHEET MEDICAL HISTORY NURSES’ NOTES SPECIAL RECORDS AND REPORTS ( referrals, x-ray reports, laboratory findings, report of surgery, anesthesia record, flow sheets, vital signs, I&O, medications)
- Is a system of organizing documentation to place the primary focus on patient’s individual problems.
- Data are organized by problems or diagnosis
PROBLEM-ORIENTED MEDICAL RECORD (POMR)
what are the four major sections of POMR
data base
problem list
plan of action
notes on progress
- Contains all available assessment information pertaining to a patient
- Provide the foundation for identifying patient problems and planning care.
DATA BASE SECTION
what can you find in a data base section
> History and Physical Assessment > Nursing Admission History and Ongoing Assessment >Physical Therapy Assessment >Laboratory Reports >Radiological Test Results
- Includes a patient’s physiological, psychological, social, cultural, spiritual, developmental and environmental needs.
- Team members list the problems in CHRONOLOGICAL ORDER and file the list in the patient’s record to serve as an organizing guide for patient care.
. PROBLEM LIST:
Disciplines involved in a patient’s care develop a care plan or plan of care for each problem.
Nurses document the plan of care in a variety of formats; generally all of these formats include nursing diagnosis, expected outcomes, and interventions.
PLAN OF ACTION (CARE OF PLAN):
Health care members monitor and record the progress made toward resolving a patient’s problems in progress notes.
Health care providers write progress notes in one of several formats or structured notes within a POMR.
NOTES ON PROGRESS (PROGRESS NOTES):
this is data based on what the patient tells you
SUBJECTIVE
