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What is documentation?

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is the written or typed legal record of all pertinent interactions with the patient— assessing, diagnosing, planning, implementing, and evaluating

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Consistent with professional and agency standards

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Characteristics of Effective Documentation

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Complete, accurate, concise, factual, organized and timely, Legally prudent, and confidential are all examples of

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Characteristics of Effective Documentation

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What is the patient record?

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is a compilation of a patient's health information

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Discuss Confidentiality?

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All information about patients is considered private or confidential, whether written on paper, saved on a computer, or spoken aloud

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What information is consider confidential

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Name, address, phone, fax, social security; reason the patient is sick; treatments patient receives; information about past health conditions

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Discuss HIPAA?

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HIPAA legislation includes punishments for anyone caught violating patient privacy. Those who do so for financial gain can be fined as much as $ 250,000 or go to jail for as many as 10 years! Even accidentally breaking the rules can result in penalties— and embarrassment— for you and your organization.

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As a patient under HIPAA what are some of your rights

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See and copy their health record; Update their health record; Get a list of the disclosures a healthcare institution has made independent of disclosures made for the purposes of treatment, payment, and healthcare operations; Request a restriction on certain uses or disclosures; Choose how to receive health information

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Discuss the purpose of the patient record in reference to Communication

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purpose of the patient record is to help health-care professionals from different disciplines ( who interact with the patient at different times) communicate with one another

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Discuss the purpose of the patient record in reference to Diagnostic and Therapeutic Orders

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diagnostic studies ordered for the patient since admission, the results of these studies, and related orders for care. Nurses are responsible for ensuring that these orders are entered in the patient record and implemented

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Discuss the purpose of the patient record in reference to Care planning,

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Each professional working with the patient has access to the patient's baseline and ongoing data and can see how the patient is responding to the treatment plan from day to day

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Discuss the purpose of the patient record in reference to Quality-of-care reviewing

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Charts might be reviewed to evaluate the quality of care patients have received and the competence of the nurses providing that care

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Discuss the purpose of the patient record in reference to research

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might study patient records, hoping to learn how best to recognize or treat identified health problems from the study of similar cases

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Discuss the purpose of the patient record in reference to Decision Analysis

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Information from record review often provides the data needed by administrative strategic planners to identify needs and the means and strategies most likely to address these needs

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Discuss the purpose of the patient record in reference to Education

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reading a patient's chart can learn a great deal about the clinical manifestations of particular health problems, effective treatment modalities, and factors that affect patient goal achievement.

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Discuss the purpose of the patient record in reference to Legal documentation

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documents that might be used as evidence in court proceedings; therefore, they play an important role in implicating or absolving health practitioners charged with improper care. The record can also be used in accident or injury claims made by the patient

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Discuss the purpose of the patient record in reference to reimbursement

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are used to demonstrate to payers ( insurance companies) that patients received the care for which reimbursement is being sought

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Discuss the purpose of the patient record in reference to Historical documentation

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Years later, information concerning a patient's past healthcare might be pertinent

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source-oriented record

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one in which each healthcare group keeps data on its own separate form. Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, and so on. Notations are entered chronologically, with the most recent entry being nearest the front of the record.

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What is a disadvantage of source-oriented record

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The main disadvantage is that data are fragmented, making it difficult to track problems chronologically with input from different groups of professionals

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What is a advantage of source-oriented record

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An advantage of the source- oriented record is that each discipline can easily find and chart pertinent data.

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Problem oriented record

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organized around a patient's problems rather than around sources of information. With POMRs, all healthcare professionals record information on the same forms

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What is one type of problem oriented record

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S O A P (subjective data, objective data, action, plan)

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What is the advantage of problem oriented records

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the healthcare team work together to formulate a problem and contributes collaboratively to the care of the patient

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Pie (Problem intervention evaluation)

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The plan of care is incorporated into the progress notes in which problems are identified by number ( in the order they are identified). In this documentation system, a complete patient assessment is performed and documented at the beginning of each shift

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Focus Charting

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is to bring the focus of care back to the patient and the patient's concerns. Instead of a problem list or list of nursing or medical diagnoses, a focus column is used that incorporates many aspects of a patient and patient care

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What is an example of focus charting

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D A R ( Data, Action, Responses)

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Charting by exception

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only significant findings or " exceptions" to these standards are documented in narrative notes

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Case management mode

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Standardized form that will need to be individualized to fit the patient needs

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Discuss minimum data sets.

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specific categories of information will use uniform definitions to create a common language among multiple health-care data users

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progress notes

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Notes written to inform caregivers of the progress a patient is making toward achieving expected outcomes (narrative notes in source-oriented records)

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flow sheets

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are used for recording information that is monitored over time.

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What are the 4 types of flow sheets

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Graphic record, 24-hour fluid balance record, medication record, 24-hour patient care records and acuity charting forms

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critical/collaborative pathways

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standardized plan of care that is developed for a patient population with a designated diagnosis or procedure. It includes expected outcomes, a list of interventions to be performed, and the sequence and timing of those interventions

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Describe the purpose and correct use for nursing assessment in nursing documentation

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A typical form used to record the initial database obtained from the nursing history and physical assessment. Accurate documentation of these data is important because it provides a baseline for later comparisons as a patient's condition changes

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kardex and patient care summary

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The plan is eventually placed in the patient's health record. The outside of the card ( activity and treatment section) contains basic information such as the patient's profile, admitting diagnosis, and orders concerning activity levels, diet, vital signs, diagnostic tests, medications, and other treatments and procedures. The inside of the Kardex contains the nursing care plan specifying nursing diagnoses and health problems, related outcomes and nursing interventions, and special safety precautions

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plan of nursing care

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may be written separately or incorporated into a multi-disciplinary plan. In a traditional plan of nursing care, nursing diagnoses, goals and expected outcomes, and nursing interventions are written for each patient

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discharge and transfer summaries

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should be written that concisely summarizes the reason for treatment, significant findings, the procedures performed and treatment rendered, the patient's condition on discharge or transfer, and any specific pertinent instructions given to the patient and family

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What is reporting?

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is to give an account of something that has been seen, heard, done, or considered. Reporting is the oral, writ-ten, or computer- based communication of patient data to others

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What is a change-of-shift report?

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is given by a primary nurse to the nurse replacing him or her or by the charge nurse to the nurse who assumes responsibility for continuing care of the patient.

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Discuss transfer and discharge reports

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Nurses report a summary of a patient's condition and care when transferring patients from one unit or institution or agency to another ( e. g., from the postanesthesia care unit to a surgical floor) and when discharging patients. The nurse making the report should concisely summarize all the patient data that caregivers need to provide immediate care

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Discuss reports to family members and significant others.

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keeping the patient's family and significant others updated about the patient's condition and progress toward goal achievement. Always clarify with the patient which visitors, if any, are entitled to progress reports Similarly, clarify what types of information may be communicated and be familiar with agency policy about such communications

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What is an incident report?

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also termed a variance or occurrence report, is a tool used by healthcare agencies to document the occurrence of anything out of the ordinary that results in or has the potential to result in harm to a patient, employee, or visitor

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What is consultation?

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The process of inviting another professional to evaluate the patient and make recommendations to you about his or her treatment

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What is referral?

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The process of sending or guiding the patient to another source for assistance

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What is a nursing care conference?

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is a meeting of nurses to discuss some aspect of a patient's care. For example, several nurses

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What is a nursing care round?

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are procedures in which a group of nurses visit selected patients individually, at each patient's bedside. The primary purposes of nursing care rounds are to gather information to help plan nursing care, to evaluate the nursing care the patient has received, and to provide the patient with an opportunity to discuss his or her care with those administering it

Chapter 17 – Documenting, Reporting & Conferring – Flashcards

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