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the written or typed legal record of all pertinent interactions with the patient-assessing, diagnosing, implementing, and evaluating.
Documentation should be:
complete, accurate, concise, factual, organized, and timely, legally prudent, and confidential.
American Nursing Association
What are some examples of patient confidentiality breeches?
speaking over the phone to a supposed spouse.
What is the purpose of progress notes?
to inform the caregivers of the progress a patient is making toward achieving expected outcomes
What methods are used to record the patients progress?
PIE and SOAP
What does SOAP stand for?
What does PIE stand for?
What does a collaborative pathway do?
It specifies the plan of care linked to expected outcomes along a timeline
Name six types of nursing documentation
- 1. Baseline nursing assessment
- 2. Plan of care
- 3. Progress notes
- 4. Flow sheets
- 5. Discharge and Transfer
- 6. Home-Health & long-term care documentation
What does HIPAA stand for?
What does JACHO stand for and what do they do?
Joint Commission on Accreditation of Healthcare Organizations:
Integrates use of outcomes and performance measures into accreditation process (national patient safety goals)
What is NCQA and what do they do?
- National Committee for Quality Assurance:
- Targets these areas; effectiveness of care, access & availability of care, patient satisfaction, health plan stability, use of services, costs, and health plan descriptive information
What does PHI stand for?