Nursing Documentation & Informatics – Flashcards
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informatics
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Managing and processing of information necessary to make decisions...applied to nursing practice, education and research
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data
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raw, unprocessed numbers, symbols, or words, subjective and objective, meaningless w/o context
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information
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data that have been interpreted
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informatics used throughout healthcare
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temperature readings, ID badges/numbers,
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benefits of the electronic health record
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multiple HCP can access info at same time, remote access, new info can immediately be viewed in another dept. eg lab tests, time savings, improved quality of care, info private and safe
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use of computers in evidence-based nursing practice
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provide rapid access to current evidence, online journals and articles, literature databases, eg National Guideline Clearinghouse website
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actions to use informatics in a professional and safe manner
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follow HIPPA, use personal integrity, access records according to policy, protect pw
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how automation decreases error in health care
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eliminates not legible handwriting and mistaken abbrevs, improves communication, automatically crosschecks meds, precise delivery of meds, info available at bedside
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purpose of documentation
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Legal, permanent written record Shows care provided by all care providers (chronologically) Communicates plan for patient care Documents patient responses Facts about health history Authorization of care and reimbursement occurs based on documentation Provides data to use in QI and research If it wasn't charted, it wasn't done
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written documentation
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Typically source-oriented where each section belongs to a discipline , easy to find care provided by each discipline, fragmented - can be difficult to see the big picture, problem-oriented records, + common problem list, easier to see the patient picture
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guidelines for documentation
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Document the nursing process Accuracy Subjective/objective data Use approved abbreviations and terminology Non-judgmental language Be specific Prompt After care has occurred Link symptom with intervention Chronologically Correct date/time/record Correct mistakes according to policy
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guidelines for completing an incident report
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...
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documentation
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act of recording pt status and care in written or electronic form, or both aka recording, charting
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reporting
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oral communication about a pt's status
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health record
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document care, pt's response to interventions, important facts re: client's health history including past and present illness, exams, tests, treatments, and outcomes
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client record
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collection of printed or electronic materials that form a legal record of the client's healthcare experience
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source oriented records
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members of each discipline record their findings in a separately labeled section
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problem oriented records
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members of each discipline chart on shared notes and record is organized around a problem list
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electronic health records
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may find combo of source and problem oriented records
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narrative notes
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nurse writes story of what has happened in the order in which it has happened, takes a long time to read
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PIE charting
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organizes info according to pt's problems, interventions and evaluation, doesn't address holistically or document planning
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soap charting
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used to address single problems or write summative notes on a pt.
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soap
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subjective data, objective data, assessment, plan, can be used in source or problem oriented
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soap charting - A
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where you write a conclusion, diagnosis, or problem, "data" is what you think the data means
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focus charting
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enter data in DAR format, data, action, response, encourages viewing status from positive perspective, good for repetitive care
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CBE charting by exception
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unless separate entry is made, all standards have been met and pt has responded as expected (entries are exceptions), decreases time spent charting, but may cause inadvertent omissions
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FACT charting
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flowsheets, standardized assessments, concise progress notes, and entries documented when care is given, similar to CBE
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ANA standards of practice
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states the need to document relevant data in a retrievable manner, requires documentation of nursing process
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flowsheets and graphic records
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used to record reoccurring assessments and care, such s vitals, I&O, weight, ADL's
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medication records
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contain detailed records about medications been rx'd for and administered to the pt
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cardex
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special form summarizing pt's plan of care
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ipoc
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combined charting and care plan form that maps out patient outcomes, interventions, and treatments for specific commonly seen diagnosis or condition, pathway pt is expected to follow
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occurrence/incidence report
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formal record of unusual occurrence or accident such as a pt fall or medication error, near miss, not part of pt's chart
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when to chart
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as soon as possible after care, never before care
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no no's
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don't use white out, erase things, leave blank lines, unauthorized abbreviations
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what to chart
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interventions, pt's response, significant events, occurrence, attempts to contact pcp, attempts to clarify orders, teaching, restraints, refusal of treatment/medication
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oral reporting
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reports to other
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change of shift report
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given to alert next caregiver about client states, change in condition, planned activities, tests/procedures, concerns that require follow up
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CUBAN
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confidential, uninterrupted, brief, accurate, named nurse (best to receive nurse who has delivered care directly)
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SBAR
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use for handoff reports, situation, background, assessment, recommendations
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PACE
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pt/problem, assessment/actions, continuing/changes, evaluations
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telephone order
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repeat order back immediately to confirm
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all documenting must be
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dated, timed, signed
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Telehealth
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the use of telecommunications to send healthcare information between patients and professionals at different locations
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goal of all nursing documentation
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clear, concise representation of the client's healthcare experience that is easily accessible and understood by all members of the healthcare team
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nursing process
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assessment, diagnosis/analysis, outcomes/planning, implementation, evaluation
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nursing process: assessment
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document signs and symptoms that may indicate pt problems, document data about all systems for initial
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nursing process: diagnosis/analysis
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document nursing judgment formed after analyzing assessment about pt's response to actual or potential health conditions/needs
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nursing process: outcomes/planning
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measurable and achievable short-term and long-term plan of care with goals directed at preventing, minimizing, resolving identified problems
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nursing process: implementation
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putting plan of care into effect, and documenting specific interventions used
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nursing process: evaluation
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client responses to nursing care and where it worked and modify plan as needed
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SOAPIER
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subjective, objective, assess, plan, intervention, evaluation, revision
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nursing progress notes
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Narrative PIE SOAP/SOAPIE/SOAPIER Focus FACT
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Admission paperwork
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Establishes baseline Identifies patient supports Contains critical information Address physiological, psychosocial, spiritual, developmental, sociocultural
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Discharge summary
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Final note in patient record Documents how the patient left the facility Discharge instructions given
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abbreviations not to use
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Trailing zero X.0 Lack of leading zero 0.X > and < @ MS MSO4 MgSO4 U IU QD QOD cc
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CINHAL and Medline
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databases
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laws
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constitution of state and fed gov't, statutes, rules by administrative agencies, decisions made by courts
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HIPAA
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protect health ins benefits for workers who lose or change jobs, protect coverage for pre-ex, personal info and privacy protection
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EMTALA
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Emergency Medical Treatment and Active Labor Act; provide emergency medical treatment to pt's in ED regardless of ability to pay, legal status, citizen status, must provide emergency screening and stabilize
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PSDA
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pt self determination act, pt's right to make decisions regarding own healthcare, based on info provided by HCP , regarding medical or surgical treatment options
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living will
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legal doc prepared by an alert and oriented individual that gives directions to others about person's wishes regarding life-prolonging treatments if person becomes unable to to make decisions
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durable power of attorney
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ID's a person who will make healthcare decisions in event pt is unable to do so
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Americans with Disabilities Act
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Protects against discrimination based on disabilities. Reasonable accommodations must be made for employees.
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Mandatory Reporting
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If you know or suspect: physical, sexual or emotional abuse or neglect of children, older adults or the mentally ill, must report to DHHS
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Mandatory Reporting at work
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You have a responsibility to report if you believe a colleague is impaired while at work.
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Good Samaritan Laws
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designed to protect from liability those who provide emergency care, person providing care did not cuase injury/emergency, care provided in competent manner, not paid, person did not object, call 911, don't leave person,
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provides Guidelines for reasonable and prudent nursing care
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Nurse practice act Your facility policy/procedures ANA Code of Ethics and Standards of Practice Patient Care Partnership
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Grounds for disciplinary action per the Maine State Board of Nursing:
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fraud use of substances that would interfere with performing duties mental/physical diagnoses that would result in pt endangerment allowing someone to practice who is not licensed incompetency unprofessional conduct any crime involving dishonesty or lying related to licensure false advertising or misrepresentation.
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criminal law
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The government brings charges against a person.
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civil law
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Involves a dispute between individuals or entities.
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libel
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Written
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slander
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verbal
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intentional tort
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Action by one person with the intent to harm another. Assault Battery False Imprisonment Invasion of Privacy Fraud
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Negligence
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failure to act in a reasonable and prudent manner
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Malpractice
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failure of a professional person to act in a reasonable and prudent manner.
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restraints
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check every 30 minutes, q2h remove restraint and assess skin/move pt, re-ordered q24h
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informed consent
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permission for any and all types of care, given by pt with full knowledge of risks, benefits, costs, alternatives, for admission/invasive/specialized/diagnostic, consent must be written and signed by pt
