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Vocabulary words from the documentation chapter (17) from Taylor Fundamentals of Nursing

Documentation

Written or typed legal record of all pertinent interactions with the patient - assessing, diagnosing, planning, implementing, and evaluating.

Patient Record

Compilation of patient's health information

Source-oriented record

one in which each healthcare group keeps data on its own separate form. Sections designed for nurses, physicians, lab, x-ray, etc.

Advantage of source-oriented record

Each discipline can easily find and chart pertinent data

Disadvantage of source-oriented record

Fragmented data -- making it difficult to track problems chronologically with input from different groups of professionals

Progress notes

Narrative notes that address routine care, normal findings, and patient problems identified in the plan of care

Problem-oriented medical record (POMR)

Organized around a patient's problems rather than around sources of information

What are the three methods of communication central to the nurses' professional role?

documenting, reporting, and conferring

What are the purposes of patient records?

Communication, Diagnostic and therapeutic orders, care planning, quality review, research, decision analysis, education, legal documentation, reimbursement, historical documentation

Advantage of problem-oriented medical record

Entire healthcare team works together in identifying a master list of patient problems and contributes collaboratively to the plan of care

SOAP format

subjective data, objective data, assessment, plan

PIE Charting

Problem, Intervention, Evaluation - system is unique in that it does not develop a separate plan of care. Instead the plan of care is incorporated into the progress notes in which problems are identified by number.

Advantage of PIE

Promotes continuity of care and saves time because there is no separate plan of care

Disadvantage of PIE

Nurses need to read all the nursing notes to determine problems and planned interventions before initiating care

Focus charting

bring the focus of care back to the patient and the patient's concerns. Topics include patient concerns and behaviors, therapies, responses, changes of conditions, significant events

Advantage of focus charting

Holistic emphasis on the patient and the patient's priorities

Charting by exception (CBE)

Shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes

Advantages to CBE

Decreased charting time, greater emphasis on significant data, easy retrieval of significant data, timely bedside charting, standardized assessment, greater interdisciplinary communication, better tracking of imp. Patient responses, and lower costs

Disadvantage to CBE

Limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing

Limitation of case management model

Works best for "typical" patients with few individualized needs

Personal Health Records (PHRs)

Records that contain the individual's medical history including diagnoses, symptoms, and medications.

Flow sheets

Documentation tools used to record routine aspects of nursing care

Discharge and transfer summary

Summarizes reason for treatment, significant findings, procedures performed and treatment rendered, patient's condition on discharge or transfer, and any specific pertinent instructions given to the patient and family

Change-of-shift report

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

Confer

Consult with someone to exchange ideas or to seek information, advice, or instructions

Consultation

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

Referral

Process of sending or guiding the patient to another source for assistance

Incident Report

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

What are some problems with charting?

Crucial omissions, meaningless repetitious entries, inaccurate entries, and the length of time involved

What information about patients is considered private or confidential?

EVERYTHING -- written on paper, saved on computer, or spoken out loud. Names, Address, Telephone #, Fax #, SSN, reason person is sick, treatment, Information about PMH

What is documentation used for?

Facilitation of patient care, serve as a financial and legal record, help in clinical research, and support decision analysis

What is the verbal order sequence?

1. Record the orders in the medical record.
2. Read the order back to verify accuracy
3. Date and note the time
4. Record V.O., name of MD, who issued the order, followed by nurse's name & title

Major parts of the POMR

Defined database, problem list, care plan, progress notes

Disadvantage of focus charting

Some nurses feel that DAR (Data, Action, Response) categories are artificial and not helpful when documenting care

What format is necessary for focus charting?

DAR (Data, Action, Response)

Advantage to case management model

Collaboration, communication, teamwork among disciplines, and efficient use of time increases quality

Computerized Documentation and Electronic Medical Records (EMR)

Calls up admission assessment tool. Develop a plan of care using computerized care plans available (NANDA list). Adds to patient database as new data is identified and modifies the plan of care. Receives a work list showing the treatment, procedures, and medication necessary. Documents care immediately using bedside computer.

Long-term care documentation

Specified by Resident Assessment Instrument (RAI) and helps staff gather information on strengths and needs, and addresses these in individualized plans of care

SBAR communication

Situation, Background, Assessment, Recommendation

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