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
This is what you observe and see
OBJECTIVE
What you think is going on based on your data
ASSESSMENT
this is what you are going to do, you can add to it to better reflect nursing progress
PLAN
specific interventions implemented
INTERVENTION
THIS PART INCLUDES THE PATIENT’S RESPONSE TO INTERVENTIONS
evaluation
this portion includes the changes in treatment
REVISION
nurse’s or narrative notes follows this format
SOAPIE FORMAT
this method is alternatively called focus charting
FDAR METHOD
This is the subject/purpose for the note
- nursing diagnosis
- event
- patient event or concern
F- focus
This is written in the narrative and contains only subjective (what they patient says and things that are not measurable) & objective data (what you assess/findings, vital signs and things that are measurable).
D (Data):
This is the “verb” area. In this section, you are going to write here what you did about the findings you found in the data part of the note.
A (Action):
This is where you write how the patient responded to your action. Sometimes, you won’t chart the response for several minutes or hours later.
R (Response):
based on the assumption that all standards of practice are carried out and met with a normal or expected response unless otherwise documented
-longhand note is written only when the standardized statement on the form is not met
CHARTING BY EXCEPTION
What are some advantages of charting by exception?
- highlights abnormal data and patient trends
- decreases narrative charting time
- eliminates duplication of charting
what are some disadvantages or charting by exception
- requires detailed protocols and standards
- requires staff to use unfamiliar methods of record keeping and recording
- nurses so used to not charting that important data sometimes omitted
a method of organizing patient care through an episode of illness so clinical outcomes are achieved within an expected time frame and at a predictable cost
CASE MANAGEMENT SYSTEM CHARTING
-CLINICAL PATHWAY OR INTERDISCIPLINARY CARE PLAN TAKES THE PLACE OFF THE NURSING CARE PLAN
CASE MANAGEMENT SYSTEM CHARTING
T OR F: KARDEX is not a part of the permanent medical record
T
a quick reference for current information about the patient and ordered treatments
KARDEX
Usually consists of a folded card for each patient in a holder that can be quickly flipped from one patient to another
KARDEX
what information can you get from the kardex?
- room number, patient’s name, age. sex. admitting diagnosis, physician’s name
- date of surgery
- type of diet ordered
- scheduled tests or procedures
- level of activity permitted
- notations on tubes, machines, other equipment in use
- nursing orders for assistive or comfort measures
- list of medications prescribed by name
- iv fluids ordered
prescription what is the abbreviation for “before meals”?
ac (L-ante cibum)
prescription abbreviation for - twice a day
bid (L- bis in die)
prescription abbreviation for - drop as in 1 drop, 2 and so on
gtt (L- gutta)
prescription abbreviation for -at bedtime
hs (L- hora somni)
prescription abbreviation for- right eye
od* (L- oculus dexter)
prescription abbreviation for-left eye
os (L-oculus sinister)
prescription abbreviation for- by mouth
po (L- per os)
prescription abbreviation for- after meals
pc (L- post cibum )
prescription abbreviation for- as needed
prn (L- pro re nata)
prescription abbreviation for- every day or daily
qd** (L- quaque die)
prescription abbreviation for– 4 times a day
qid (L- quarter in die )
prescription abbreviation for- 3 times a day
tid (L- ter in die)
Is a digital version of patient data that is found in traditional paper records.
Accurate documentation within an HER facilitates interprofessional communication; helps to meet professionals, regulatory and legal requirements; and aids in quality improvement efforts and health care research.
ELECTRONIC HEALTH RECORDS
what does the EHR involve
physicians, clinicians hospitals radiology reports vital signs insurers laboratory data
give the two advantages of an EGR for NURSING
A means for nurses to compare current clinical data about a patient with data from previous health care encounters.
To maintain an ongoing record of health education provided to a patient and the patient’s response to that information.
Is the ORAL, WRITTEN, OR COMPUTER-BASED communication of patient data to others
REPORTING
give the types of REPORTING
ISBAR(R)
Change of Shift Reports
Incident Report
Referral System
what does the I in ISBAR indicate?
IDENTITY OF PATIENT
- name, age, ward, team
what does the S in ISBAR indicate
SITUATION
- symptom/ problem
- patient stability/level of concern
what does the B in ISBAR indicate?
BACKGROUND
- history of presentation
- date of admission and diagnosis
- relevant past medical history
what does the A In ISBAR indicate?
ASSESSEMENT & ACTION
- what is your diagnosis
- impression of situation
- what have you done so far?
what does the R in ISBAR indicate
RESPONSE AND RATIONALE
- what you want done
- treatment/investigations underway or that need monitoring
- REVIEW: by whom, when and of what?
- plan depending on results/clinical course
T OR F: ISBAR can be brief
TRUE
this type of report is given to all nurses on the next shift
CHANGE-OF SHIFT report
what does the change-of-shift report include?
- up-to date information about a patient’s condition, required care, treatments, medications, and any recent or anticipated changes
this type of report is done in any event that is not consistent with the routine operation of a health care unit or routine care of a patient
INCIDENT OR OCCURRENCE REPORTS
give some examples of incidents
- patient falls
- needlestick injuries
- visitor having symptoms of illness
- medication administration of errors
- accidental omission of ordered therapies
- circumstances that lead to injury or risk for patient injury
The process of sending or guiding the patient to another source for assistance
REFERRAL SYSTEM
______ are especially important in providing continuity of care for people who need a variety of services.
Referrals
Serves to replace the paper documents, file folders, and filing cabinets
HEALTH CARE ELECTRONIC DATABASES
this is the most commonly used database in healthcare.
one that a single computer applications runs on.
It allows for quick, real-time transactional processing
OLTP (ONLINE TRANSACTION PROCESSING)
LIST some of OLTP uses
Electronic Health Record (EHR) Laboratory system Financial system Patient satisfaction system Patient identification Billing and payment processes Human Resource
