Week 5 Flashcards
What is Documentation ?
is a nursing action that produces a written account of pertinent patient data, nursing clinical decisions, interventions, and patient responses
effective documentation decreases the risk in errors
What are the purposes of medical records ?
- Communication and care planning
- Legal Documentation: there are 8 common charting mistakes (1. failing to record pertinent health or drug information 2. failed to record nursing actions 3. failing to record medications that have been given 4. recording on the wrong chart 5. failed to document discontinued medication 6. failing to record drug rxns or changes to in the patients condition 7. transcribing orders improperly 8. writing ineligble or incomplete records
- funding and resource management
- auditing and monitoring
- research
- Education
What is EHR and EMR ?
EHR is Electronic Health Record and EMR is Electronic Medical Record - these two terms are used interchangeably with one another, however there are differences between the two
EHR is used increasingly in longitudinal record of all health care encounters for an individual patient
EMR is the legal record tha describes a single encounter or visit created in hospitals and outpatient health care
What components is an EHR supposed to have ?
- provide longitudinal or lifetime patient record by linking all patient data
- indiciating a problem list
- Required the use of standardized measures to evaluate and record health status and functional problems
- provide a method for documenting
- support confidentiality, privacy, and audit trails
- provide continous access to authorized users
- allow multiple health care providers acess to customized views
- support the use of decision analysis tools
- support direct entry of patient data by physicians
- include mechanisms for measuring costs and quality of care
- support existing and evolving clinical needs
What is the personal information protection and electronic documents act (PIPEDA) ?
is federal legislation that protects personal information including health information
What is a patients record ?
A patients record or chart is a confidential, permanent legal document of informtion relevant to patients health care
What are reports ?
What is consultation ?
What is referrals?
Reports or Oral, written, or audiotaped exchanges of information between caregivers
are another form of discussion whereby one professional caregiver gives advice about the care of patient to another caregiver
consulations and conferences must be documented is a patients permanent record so that all caregivers plan care accordingly
What are the guidlines for quality documentation and reporting ?
- Factual: contais descriptive, objective information about what a nurse sees, feels, hears and smells - do not use word appears, seems, apparently
- Accurate: uses accurate measurements - most healthcare systems use standartd symbols, abbreviations, and acronyms
- Complete: information must be complete, appropriate and containing essential information
- Current: timely entries are important for a patients ongoing care
- Organized: logical order
- Compliant with standards
what are the methods of documentation ?
- Narrative Documentation: storylike format
- Problem oriented health care records or Health care records: primary focus is patients individual problems, it contains the following major sections (1. Database 2. problem list 3. care plan 4. progress notes (one method is subjective objective assesment plan SOAP or SOAPIE in which intervention and evaluation is added another method for progress notes is PIE which is problem intervention evaluation or a third format is Data Action Response DAR
- Source Records: patient record is arranged in such a way that each discipline has a seperate action
- Charting by Exception CBE: patient meets all standards unless otherwise documented - instead of writing normal statements like Within defined limits (WDL) or Within Normal Limits (WNL)
- Case Management and Use of Critical Pathways: interdisciplinary approach to documenting patient care and its summarized into critical pathways for specific diseases and guidlines - sometimes unexpected occurences occur which are called Variances
What are common record keeping forms ?
- Admission Nursing forum
- Flow sheets and graphic records
- Patient Care Summary or Kardex: Kardex is a flip over file or binder which is kept at the nursing station
- Standarized Care Plans
- Discharge summary forms
What are Acuity Rating Systems ?
Acuity ratings is used to determine the number of hours of care and number of staff required for a give group of patients every shift or every 24 hours
What are the ways to document communication with providers and unique events ?
- Telephone calls made to healthcare providers
- telephone and verbal orders: written as TO (telephone order) or VO (verbal order)
- Change to shift reports: these reports are given in person, by audiotape recording, writing information in summary report or standing at patients bed side - Transfer of accountability (TOA) are guidelines that are followed by nurses and an organized report follows the followig seqeunce (1. background information, 2. Assessment, 3. Nursing DIagnosis, 4. Teaching plan, 5. Treatments, 6. Family information, 7. discharge plan, 8. priority needs
- Transfer Reports: promotes continuity of care - when giving transfer reports the following information needs to be given (name, age, primary physicial, medical diagnosis, summary of progress, allergies, current health, emergency code status, patients family support, patiets nursing diagnosis/care plan/probelm, need for special equipment
- Using ISBAR or ISBARR
- Incident or Occurence Report
