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What does a health record permanently document?
- Care, in chronological order, provided by all health-care providers
- Patient's response to interventions and treatments
- Important facts about the patient's health history, including past and present illnesses, examinations, tests, treatments, and outcomes
What is the goal of documentation and what does it utilize?
- The goal is clear concise representation of the patient's healthcare experience that is easily accessible and understood by all members of the healthcare system
- Utilizes the nursing process
What does documentation serve as?
- Proves compliance with standards set by the Joint Commission
- Linked to Medicaid and Medicare reinbursement
- Legal document
What are the health record systems?
- Source-oriented record system
- Problem-oriented record system
- Charting by exception
- Electronic Health Record (EHR)
- Paper Health Record System
What are some legal guidelines to follow when charting?
- Correct errors promptly using appropriate method
- Do not leave any blank spaces in nurse's notes
- Write legibly in black ink
- Always start with date and time and end with signature
What is the narrative method of documentation?
- Tells the story of the patient's experience in chronological time
- Goal is to track the client's changing health status and progress towards goals
What is the SOAPIE format of documentation?
- S: subjective data
- O: Objective data
- A: Assessment
- P: Plan
- I: Intervention
- E: Evaluation
- (R: Revision)
What is the systems charting method of documentation?
Document systems assessments from head to toe
What is the charting by exception method of charting?
- Uses an initials sheet
- Initial what is normal
- Document anything abnormal
What is the focus charting method of documentation?
- Uses assessment data to evaluate client care concerns, problems, or strengths
- Works well in acute care settings and in areas in which the same care and procedures are repeated frequently
Who decides what nursing abbreviations are appropriate?
The Joint Commission
How do you document a late entry?
- Date, time, reason for entry
- Write relevant times for data
- mark-Late Entry
What is SBAR reporting?
Helps to insure important information is shared among health care providers
- S: Situation
- B: Background
- A: Assessment
- R: Recommendations
How do you take a TO?
- Repeat it clearly for confirmation and clarification
- Repear until completely understood
- A witness may be used
- Signed the next day by MD
How do you take a VO?
- Happens more often in emergency situations
- Recording a VO includes: date, time, written text of order/electronic entry of order, indicator such as "VO"
What are clinical pathways?
Standardized care plan for patients depending on condition
What are nursing informatics?
- A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice
- Healthcare information system (HIS): a group of systems used in a health care organization to support and enhance health care
What is the most important thing about documentation?
If you do not document it then it did not happen!!!
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