5. medical record ( Documentation forms)

Card system used to consolidate patient orders and care needs in centralized, concise way. Kept at the nursing station for quick reference.
Nursing Care Plan
Nursing Care Plan: Preprinted guidelines used to care for patients with similar health problems.
nursing, patient
Nursing Care Plan: Developed to meet the _________ needs of a ________
assessment, diagnosis
Nursing Care Plan: Based on nursing __________ and nursing ________ (not the med diagnosis)
nurses, nurses
Nursing Care Plan: Developed for ________ by _________
Incident report
Form that is filled out with any event not consistent with the routine care of patient
consistent, omission on med, incorrect med/dose
Incident Report: Used when patient care was not ___________ with facility or national standards of expected care (_________ ___ _______; _________ _______/________)
Incident Report: Give only ___________, observe information (QA/RM) Quality assurance
liability, unnecessary
Incident Report: Do not admit _________ or give __________ details
incident report, nurses notes
Incident Report: Do not mention the in the nurses notes
24- Hour Patient Care Records and Acuity Charting Forms
Consolidation of the nursing records into a system that accommodates a 24-hour period is often done. (Flow sheets and Checklists)
aids, elimination, unnecessary, forms
24- Hour Patient Care Records and Acuity Charting Forms: This ______ in the _________ of __________ record-keeping _______.
assessment, documentation, ADls, easily, 24
24- Hour Patient Care Records and Acuity Charting Forms: Accurate __________ information and ___________ of _________ are more easily obtained with _____-hour notations.
provided, after, discharge
Discharge summary forms: Information is ________ that pertains to the patient’s continued health ______ _______.
Discharge, summary, instuctive
Discharge summary forms: __________ summary forms make the __________ concise and _________.
Managed care, framework, coordination, interventions, eliminates, care plan
Clinical (critical) Pathways: ________ _______ is a systematic approach that provides a _________ to target the __________ of medical and nursing __________ , __________ the nsg ______ ______
all, integrated, stay, case
Clinical (critical) Pathways: Allows staff form _____ disciplines to develop _________ care plans for a projected length of _____ for a specific _____ type.
progress, documentation tool
Clinical (critical) Pathways: The nurse and other team members use the pathways to monitor a patient’s _________and as a ____________ (nsg – CBE charting by exception) _______
Home health care
Medicare has specific guidelines for establishing eligibility for ______ _______ _______ reimbursement. (more paperwork)
problem, 50%, documentation, narrower scope of witnessed- pt, family, direct care
Home health care documentation: Documentation by home health care nurses has become the largest _______ are: _____% of nursing time is spent in ___________. (d/t________ _________ of __________ – pt, _________, _______ _______)
quality , justification, reimbursement, medicare, medicaid
Home health care documentation: Documentation is both the ________ control and the __________ for __________t from _________, _________, or private insurance companies.
different, access, medical record
Home health care documentation: Home health care documentation has unique problems because of the need for ________ health providers to ________ the _______ ________.
-Assessment form
-Referral source information/intake form
-Discipline specific care plans
-MD plan of tx
-Medication sheet
-Clinical progress note
-Misc (conference notes, verbal order (V.O.) form, phone calls.
-Discharge summary
-Reports to third-party payers
Home health care documentation: Forms used for documentation are;

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