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Definition of documentation?
Anything written or printed within a client record
Definition of a record?
A permanent legal writte ncommunication that includes information relevant to a client's health care management.
How can information (such as records or documents) be transfered?
Who has legitimate access to patients' records?
Only staff directly involved in patients' care.
What is HIPPA?
Health Insurance Portability and Accountability Act - patient has the right to know what their records say, and must give permission in order for the records to be given to someone else. Pt must also be notified of who their records are going to.
Nurses have a legal and ethical obligation to maintain ________ ? (regarding patients and their records)
What is TJC?
The Joint Commission - an accreditation agency that specifies guildelines for documentation.
What assessments are required by The Joint Commission of all clients admitted to a healthcare institution?
- Client education
- Discharge planning
Who sets nursing documentation standards?
Federal and state regulations, state statutes, standards of care, and accrediting agencies
What is the purpose of records?
- Legal documentation
- Financial billing
- Nursing process
- Auditing and monitoring
What are the five important characteristics of quality documenting and reporting?
What types of phrases/words should be avoided when documenting?
Anything generalized such as "had a good day" or words like "seems"/"apparently". This type of documentation is subjective and does not reflect client assessmnet. Complete, concise descriptions of care should be used.
What is narrative documentation? Some disadvantages?
- The traditional method for recording nursing care. The use of a storylike format to document information specific to client conditions and nursing care.
- Disadv: repetitive, time-consuming, requires reader to sort through lots of info to find data
What is a problem-oriented medical record (POMR)?
A method of documentation that emphasizes the pt's problems; data is organized by problem/diagnosis.
What are the four components of a problem-oriented medical record (POMR)?
- Problem list
- Nursing care plan
- Progress notes
What is a database?
All available assessment info pertaining to the pt (ex, history, physical examination, lab reports, radiology test results, etc)
What is a problem list?
An organizing guide for a patient's care developed by healthcare team members (including client's physiological, psychological, social, cultural, spiritual, developmental, and environmental problems).
What are progress notes?
- The monitoring and recording of the progress of a patient's problems.
- Can come in various formats or structured notes
What is SOAP(IE)?
A waxy block used in the shower to clean dat sexy bod ;) JK JK
- A method of progress report:
- S- Subjective data
- O- Objective data
- A- Assessment
- P- Plan
- I- Intervention
- E- Evaluation
What is PIE?
- A method of problem-oriented progress reporting:
- P- problem
- I- intervention
- E- evaluation
What is DAR?
- A method of focus charting:
- D- Data (both subjective & objective)
- A- action or nursing intervention
- R- response of the client
What is the difference between focus charting and problem-oriented charting?
- Focus charting addresses client concerns such as a sign or symptom, a condition, nursing diagnosis, behavior, or significant event.
- Problem-oriented is more focused on a problem, and has more of a negative connotation.
What is charting by exception (CBE)?
- A documentation method that focuses on abnormal findings. It reduces documenting time and highlights trends/changes in the client's condition.
- The chart is mostly standardized, allowing the nurse to only have a need to document when there is a significant finding that strays from the norm.
What is the case management model of delivering care, with critical pathways?
A multidisciplinary approach to documentation. The critical pathways are care plans that include client problems, interventions, and expected outcomes within an established time frame. Nurses and other team members all can access the computerized critical pathway document to monitor the client's progress during each shift.
What is an admission nursing history form?
A form completed when a client is admitted to a nursing care unit. Provides baseline data to compare with changes in the client's condition.
What is a flow sheet?
- A form that allows nurses to quickly and easily enter assessment data about the client, including vitals and routine care (hygiene, ambulation, meals, safety/restraint checks).
- Used for their quick, easy reference in assessing a patient's status (commonly used in critical care and acute care)
What is a client care summary, or a Kardex?
- A computerized print-out for each patient during each shift. It is continually updated, providing a detailed list of orders, treatment, and diagnostic testing.
- Kardex - a portable file or notebook used for frequent updating and as a quick reference for the patient's status.
What is an acuity record?
- A record to help determine the hours of care and staff required for a given group of patients. A patient's "acuity level" is based on the type and number of nursing interventions required over a 24-hr period.
- Depending on a patient's acuity level, the patient-to-staff ratio varies.
What is a standardized care plan?
Preprinted, established guideline that is used to care for patients who have similar health problems.
What is a discharge summary form?
- A summary form including all the information a patient needs at the time of discharge.
- Includes all learned information during their stay, such as about their disease process, likely signs/symptoms they may see, how to perform a certain procedure, and other resources they may need.
What is a variance?
An unexpected outcome, unmet goal, or intervention not specified within a critical pathway timeframe.
What is a report?
- Transfer of information from the nurses on one shift to the nurse on the following shift.
- May also be given by a nurse to another health care provider.
- Information of a client's status or a change in status can be reported over the phone from another unit, or from another healthcare professional.
- Useful method to verify information
- Readback is required if critical values are being reported
Telephone order (TO)
- Involves a physician's stating a prescribed therapy over the phone to a registered nurse.
- Must be verified with a readback of the complete order.
- RN must also record it on an order sheet and sign it.
Verbal order (VO)
An order that should only be accepted when there is no opportunity for a physician to write the order, as in emergency situations
What is a transfer report?
- A report of patient information from one unit to another (ex, from the ICU to the recovery room).
- Can be given by phone or in person
What is medication reconciliation?
- An accurate list of all client meds from admission through to discharge.
- With each transfer within the institution, the list of meds must be reconciled for accuracy
What is nursing informatics? (LOL GOOD ONE MICHELLE ROGERS sneaking into our nurs200 class)
- The integration of nursing science, computer science, and information sceince to manage and communicate data, information, and knowledge in nursing practice.
- Plays an important role in helping nurses make decisions more rapidly and more accurately
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