Chapter 9

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  1. What does SBAR stand for?
    Situation, Background, Assessment and Recommendation
  2. What is the purpsoe of documentation and reporting?
    • Documentation and reporting are necessary to enhance efficient, safe, indiviualized patient care.
    • Documentation serves multiple purposes, including communication, legal documentation, reimbursement, education, research, and auditing and monitoring.
  3. What are 5 characteristics of high quality documentation and reporting?
    • Factual
    • Accurate
    • Complete
    • Current
    • Organized
  4. Factual:
    • A record contains descriptive, objective information about what you see, hear, feel and smell.
    • Objective data are data that are meassurable and observable.
    • To be factual, avoid words such as appears, seems, or apparently.
    • The only subjective data included in a record are whhat the patient says. It is also important to include complementary objective findings so that your data base is as describtive as possible.
  5. Accurate:
    • The use of precise measurements makes documentation more accurate.
    • The Joint Commision requires that all entries in medical records be dated and that there is a method to identify all authors of entries.
  6. Complete:
    The information within a recorded entry needs to be complete, containing appropriate and essientail information.
  7. Cuurent:
    Making entries promptly is essential in effective documentation.
  8. Organized:
    • Written communication is easier to understand when written in logical order.
    • An organized note describes your assessment, interventions, and the patients response in a sequence.
    • Notes are concise, clear, and to the point are also more effective.
  9. Effective communication takes place along approaches, the patients:
    • Record
    • Reports
  10. What is documentation?
    Defined as anything written or printed within a patient record, which may be either paper, electronic, ora combination of both formats.
  11. What does HIPPA stand for?
    Health Insurance Portability and Accountability Act
  12. Do nursing students have to follow HIPPA guidelines?
    Yes, when you are a student in a clinical setting, confidentiality and compliance with HIPPA legislation are part of professional practice.
  13. Record:
    Permanent written communication with patients health care management.
  14. POMR:
    • Problem-oriented medical record
    • Structured method of documentation with emphasis on the patients problems.
  15. The POMR has the following major sections:
    • Database
    • Problem list
    • Initial care plan
    • Discharge summary
    • Progress notes
  16. Database:
    • Contains all available asseessement information pertaining to the patient.
    • The foundation for identifying patients problems and planning care.
    • Remains active and current and you make revisions as new data are available.
  17. Problem List:
    • Developed after a review of the patient data.
    • You identify problems and list all problems in chronoligical order to serve an an organized guide for all for the patients care.
  18. Care plan:
    • Is developed for all patients on admission to acute, subacute, rehabililation, or extended care agencies.
    • Interdisciplinary care plan for each problem listed.
  19. Progress notes:
    • Narrative
    • Flow sheets
    • Discharge summaries
    • Structured notes
  20. Narrative notes:
    Story like format to document information specific to patients conditions and nursing care.
  21. Discharge summary forms:
    • You begin discharge planning on admissions and in some cases even before admission, as is necessary with same day surgery admissions and childbirth.
    • Primary goal of a discharge summary is to ensure the continuity of care, whether the patient is going home or transferring to another institution.
  22. SOAP documentation:
    • S: subjective data (pt states)
    • O: objective data (data that can be validated, you can see it, hear it, smell it, feel it, read it.)
    • A: assessment (A statement of the nursing diagnosis. What you have assessed the problem to be.)
    • P: plan (What you plan to do)
  23. SOAPIER:
    • I: interventions (What you did)
    • E: evaluation (What happened)
    • R: revision (Used if interventions were ineffective)
  24. Focus charting:
    • A third narrative format
    • Places less emphasis on patients problems and instead focuses on patient concerns such as a sign or symptom, a condition, a behavior, or a significant event.
    • Includes: DAR data, actions and patient response

    • The focus can be:
    • •The nursing diagnosis
    • •An exception to the expected outcome
    • •Something “new”
    • •Change in condition
    • •An unusual occurrence
  25. Data:
    Any data, subjective, or objective.

    Ex. Vitals, wound assessments, patients statements.
  26. Action:
    What you did to/ for the patient past, present, future.

    Ex. elevated head of bed, administered prn medication, notify pcp.
  27. Reponse:
    How the patient responded to your intervention clinically or verbally.

    Ex. pt states pain is at 3/10, RR now 14, denies SOB.
  28. Charting by exception (CBE)
    • innovative approach to reduce the time required to complete documentation.
    • CBE simply involves completing a flow sheet that incorporates those standard assessment criteria and interventions.
  29. Report:
    Are oral, written, or audiotaped exchanges of information between members of the health care team.
  30. Is the patient the focus of all documenation?
  31. Communication:
    The record is a way for health are team members to provide contiunity of care and to communicate patients needs and progress toward meeting desired patients outcomes.
  32. Legal documentation:
    • Effective documentation os one of the best defenses for legal claims associated with health care.
    • Your documentation must follow organizational standards for documentation, which include a clear indication of the indiviualized and goal directed nursing care you provide.
  33. Reimbursement:
    • Charting also determines the amount of reimbursement a health care agency receives.
    • DRGs are the basis for establishing reimbursement for patient care.
  34. Education:
    • Reading the patient care record is an effective way to learn the nature of an illness and the patients repsonse to the illness.
    • Review of patients with the similar medical problems allows you to identify patterns and trends.
    • Such information builds your clinical knowledge.
  35. Auditing and Monitoring:
    • Audits help to determine whether standards of care are met.
    • Nurses may monitior records to determine their success in documenting institution of fall precautions or evaluation of pain measure.
  36. Case management plan:
    A multidisciplinary model for documenting patient care that usually includes plans for problems, key interventions, and expected outcomes for patients with a specific disease or condition.
  37. Variences:
    are deviations or detours from the pathway and refer to either positive or negative changes, depending on the clinical situation.
  38. Positive variances:
    Occur when a patient profgresses more rapidly than the care management plan expected.
  39. Negative variances:
    Occurs when the activities on the clinical pathway do not occur as comes.
  40. Admission Nursing History Forms:
    Provide baseline data for later comparisons with changes in the patients condition.
  41. Flow Sheets & Graphic Records:
    Allow documentation of certain routine obeservations or specific measuements made repeatly, such as height and wieght and activities of daliy living such as the bath, vital signs, pain assessment, and intake and output.

    Critical care units use flow sheets for many types of data.
  42. Patient care summary or Kardex:
    Flip over card file: kept in the nursing station provides information for the daily care of a patient.

    Often contains two parts: activity and treatment section and a nursing care plan section.
  43. Acuity recording:
    Systems determines the hours of care for a nursing unit and the number of staff required to care for a given group of patients.
  44. Stnadarlized care plans:
    Based on the institution standards of nursing practive are preprinted established guidelines used to care for a patients with similar health problems.
  45. Hand of report
    Happens anytime one health care provider transfers care of a patient to another health care provider.

    Purpose: to provide better continuity and indiviualized care for a patient.
  46. Change of shift report:
    Is one type of hand off report that occurs at the end of each shift.
  47. Tranfers report:
    Another type of hand off report that involves communication of information about patients from the nurse on the sending unit to the nurse on the receiving unit.

    Usually completed by phone or in person.
  48. Telephone Reports and Orders:
    Sbar standardizes telephone communication of significant events or changes in the paitents condition.
  49. Telephone orders (TO) example:
    Involves a health care provider stating a prescribed therapy over the phone to a RN
  50. Verbal Order (VO) example:
    Involves the health are provider giving orders to a nurse while they are standing near each other.
  51. Incident report or occurence report:
    Occure when there is an actual or potential injury; this report is not a part of the patient record.
  52. Informatics:
    Is the science and art of turning in data into information.

    Describes the study of the retrieval, storage, presenation, and sharing of data, information, and knowledge to provide quality, safe patient care.
  53. Informatics includes:
    • Data
    • Information
    • Knowledge
    • Wisdom
  54. Three important purposes of medical records:
    • Communication
    • Education
    • Research
  55. EHR:
    Electronic Health Record
Card Set:
Chapter 9
2011-10-02 03:31:29
Basic Nursing

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