WEEK 2 SUMMARY: DOCUMENTATION Flashcards
What is the primary purpose and goal of documentation?
Facilitation on the information flow that supports the continuity, quality, and safety of care
Who can access the patients medical records?
records can be accessed ONLY by authorized personnel on a need-to-know basis, must be a part of patients healthcare team
What are some critical aspects of documentation?
- documentation must be clear, accurate, accessible, objective, timely, non-judgmental, accurate spelling and grammar
- Must be done as soon as possible after competition of tasks, changes in patient condition, interaction with any other health care provider
- Each nursing entry must include date, time, nurse signature and credential
How do you ensure the document is factual?
by objective and subjective data
What is subjective data?
whatever the patient says
What is objective data?
do not use judgmental derogatory words or your opinion
What is important to know about abbreviations?
some term cannot be abbreviated when documenting because they can easily be misinterpreted and can cause patient safety issues
What are PIE notes?
problem, intervention, evaluation
What are APIE note?
assessment, problem, intervention, evaluation
What are SOAP notes?
Subjective data, objective data, assessment, and plan
What are SOPIE notes?
Subjective data, objective data, assessment, plan, intervention, and evaluation
What are SOPIER notes?
Subjective data, objective data, assessment, plan, intervention, evaluation, revision
What are DAR notes?
Data( based on patient problem) , action, response
what is charting by exception?
record only abnormal findings and significant data
What are flow charts?
checklists to document routine care-vital signs, medication, intake and output, weight; can create a graphic visual of the data
what is MAR?
medication administration records, document medication administration immediately after meds are given. If the client refused, out client refused, if the medication is on hold put on hold, if the med is not given put not given and the reason
what are the legal aspects of documentation?
- confidentiality and privacy
- HIPPA
- patients do have the right to view their own record, must follow facility policies on this request
- patient must provide permission to share information from medical record with outside agencies
What do you do if you forgot to document something or if you note that someone else forgot to document something?
If you documented something in error, follow the facilities policy regarding correction and complete documentation as soon as possible after care is provided
