1245 documentation

19 terms by mcostakis 

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What does FACT stand for?


use first initial, last name, credential. Ex. SNMCC or RN.

Characeristics of Effective Documentation (8)

-consistent w/ professional and agency standards
-organzied and timely (tag as late entry is okay as long as chart isn't scheduled to be pulled for inquiry)
-legally prudent

What 3 things should you know about using Abbreviations?

1. use only agency approved
2. when in doubt, spell out the word
3. avoid using in pt. orders (cuts down on errors & ⬆ patient safety)

What is HIPPA (3)?

Health Insurance Portability & Accountability Act of '96
Modified and release in '02
Fines and punishments for breaking confidentality of patients

What are 5 Patient rights in HIPPA?

1. can see and copy their health record
2. update their health record (ex. correct error)
3. get a list of disclosures independent of tx, payment and healthcare operations (Ex. chart being used for something else)
4. request a restriction on certain uses or disclosures (in writing)
5. choose how to receive health information (ex. in writing, email, etc) Patient's can see in real time & nurse should review w/them, in case of questions

What information is Confidential?

1. ALL information about pts written on paper, spoken aloud, saved on computer, social networking
• name, address, phone, fac, ssn
• why the person is sick
• tx's the pt received
• information about past health conditions

What are 9 Breaches in Confidentiality?

1. displaying info on a public screen (don't leave computer untended)
2. sending confidential e-mail messages
3. sharing printers among units w/differing functions
4. discarding copies of pt. info in trash cans
5. holding conversations that can be overheard
6. faxing confidential info to unauthorized person
7. sending confidential messages overheard on pagers
8. texting confidential info
9. "Need to know" only to do your job

What is SBAR (ISBARR)?

I: identification of self and pt.
S: Situation
B: Background
A: Assessment
R: Recommendation
R: Read back (whatever orders you have received)

What is a Verbal Order, what does the RN do & what does the Provider do? (8)

1. Occurs during medical emergencies ONLY when provider is unable to write order (in middle of proc)
2. record VO, the provider name followed by the RN's name
3. record the order
4. read back the order to verify accuracy
5. date and note the time orders were used
Provider needs to:
6. always review orders for accuracy
7. sign orders w/ name, title and contact #
8. date and note time orders signed (must be signed within 24 hours)

Telephone Order (6)

-record TO, full name and title of provider who issued orders, RN's name
- record the order
-read orders back to practitioner to verify accuracy
-date and note the time orders were issued
-provider to sign order within 24 hrs
-if not signed, provider get's cited

What are 9 Purposes of Records?

-COMMUNICATION w/ other healthcare professionals
-record of diagnostic and therapeutic orders
-care planning
-quality of care reviewing
-decision analysis
-legal and historical documentation

What are 9 Formats for Nursing Documentation?

-initial nursing assessment
-Kardex and pt. care summary
-plan of nursing care (multidisciplinary)
-critical collaborative pathways
-progress notes
-flow sheets (ex. med arm, VS)
-discharge and transfer summary
-home healthcare documentation
-long term care documentation

What are 4 Types of Flow Sheets?

- graphic records (VS, I&O)
- 24 hr fluid balance record
- medication record
- 24 hr patient care records and acuity charting forms

Methods of Documentation (10)

- problem-orientated medical records
- PIE charting
- focus charting
- charting by excretion
- case management model
- computerized records

ALL formats include (doesn't matter what agency):
- assessment of data
- what was done about it (the abnormal)
- how did the patient respond (to the intervention)

DO NOT chart abnormal findings w/o intervention!!!

what is PIE?

P - Problem (data assessment)
I - intervention
E - Evaluation

What is Focus patient care notes?

Uses data, action and response

What are 2 Case management Models?

1. Collaborative pathways- helps to not miss things, based on diagnosis or intervention, there are absolute steps in the pathway to follow
2. Variance reports = charting by exception. If something didn't happen when it was suppose to.

Change of Shift Report (3)

1. basic identifying information about each pt.
2. current appraisal of each pt's health status; changes in medical conditions and pt. response to therapy, where pt. stands in relation to identified diagnoses and goals
3. current orders (nurse and Dr.)

What are 6 Methods of Reporting?

1. face-to-face meetings (rounds, help w/pt safety)
2. telephone conversations
3. messengers (ex. covering for RNs at lunch)
4. written messages
5. audio-taped messages
6. computer messages

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