Methods of communicating
documenting, reporting and conferring
written or typed legal record of all pertinent interactions with the patient.
Records that contain data are used for
facilitate patient care, serve as financial and legal records, help in clinical research and support decision analysis.
creates and environment that supports timely, accurate, secure and confidential recording and use of patient specific information.
compilation of patient's health information
specifies nursing care data related to patient assessments, nursing diagnoses or patient needs, nursing interventions and patient outcomes are permanently integrated into the patient records.
documentation should be
consistent with professional and agency standards, complete, accurate, concise, factual, organized and timely, legally prudent and confidential.
Principles of Documentation
guide includes policy statements, principles, and recommendations to assist nurses with documentation and to comply with institutional and regulatory requirements.
has website dedicated to promoting awareness, use and further development of standardized data elements and terminologies.
Health Insurance Portability and Accountability Act - 1996- written to protect the privacy of health info.
According to HIPPA, pts have right to
see/copy health records, update health records, get list of disclosures made for purposes of treatment, payment and healthcare operations, request restrictions on certain uses or disclosures. choose how to receive health information.
Purpose of patient records
communication with other workers, recording of diagnostics and therapeutic orders, care planning, quality of care reviewing, research, decision analysis, education, legal documentation, reimbursement and hisrotical documentation.
Primary purpose of patient record
help healthcare professionals from different disciplines communicate with one another.
Acceptable only in emergency situations or when it's impossible for physician/nurse practitioner to write the order
Charts might be reviewed for quality review
evaluate the quality of care patients have received and competence of the nurses providing that care
Researchers might study patient records, hoping to learn how to best recognize or treat identified health problems from the study of similar cases
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.
Education in chart review
Professionals and students reading a patients chart to learn about clinical manifestations of particular health problems, effective treatment modalities and factors that affect patient goal achievement.
Patient records as legal documents
may be used as evidence in court proceedings. Play role in implicating or absolving health practitioners charged with improper care. Also used in accident or injury claims by pt.
Pt records for reimbursement
used to demonstrate to payers that patients received the care for which reimbursement is being sought.
Historical Documentation/chart records
Used for dates of entry for pt previous health history
source oriented record
THE MOST COMMON TYPE OF RECORD, where the patient chart is separated into sections that contain forms for each discipline
advantage of source oriented record keeping
each discipline can easily find and chart pertinent data.
Disadvantage of source oriented record keeping
date is fragmented, making it difficult to track problems chronologically with input from groups of professionals.
Notes used in the patient chart to track the progress and condition of the patient.
descriptive record of the patient's condition; includes patient's response to interventions by health professionals and patient's progress toward goal achievement,
--progress notes written by nurses in a source-oriented record
Problem oriented medical record
documentation system organized according to the person's specific health problems; includes database, problem list, plan of care, and progress notes
Advantage of Problem oriented medical record (POMR)
entire healthcare team works together in identifying a master list of patient problems and contributes collaboratively to the plan of care.
method of charting narrative progress notes; organizes data according to subjective information (S), objective information (O), assessment (A), and plan (P)
PIE charting system
Problem, Intervention, Prevention.
Problems are identified by number
a complete patient assessment is performed and documented at the beginning of each shift using pre printed fill in the blank assessment forms (flow sheets)
Advantage of PIE charting system
promotes continuity of care and saves time because there is no seperate plan of care
Disadvantage of PIE charting system
Nurses need to read all notes to determine problems and planned interventions before initiating care.
intended to focus on client. 3 columns (time/date, focus, progress notes) Progress Notes column organized by (D) data, (A) action, and (R) response. Used in conjunction with flow sheets and checklists. + provides holistic perspective
advantage of focus charting
holistic emphasis on the patient and patient priorities and ease of charting.
Charting by Exception
the only thing that is documented is abnormal assessment findings and nursing care that deviates from written standards. No normal findings or routine care is charted.
Advantages of charting by Exception
decreased charting time, greater emphasis on significant data, easy retrieval of significant data, timely bedside charting, standardized assessment, greater interdisciplinary communication, better tracking of important patient responses and lower cost.
Disadvantages of charting by Exception
usefulness when trying to provide high quality safe care in response to a negligence claim made against a nurse.
Case management model
emphasizes quality, cost-effective care given within an established length of stay. promotes collaboration and teamwork among caregivers.
AKA critical pathways or care maps
used in case management model. Specifies the plan of care linked to expected outcomes along a timeline. Can be part of computerized documentation system that integrates the collaborative pathway and documentation flow sheets designed to match each day's expected outcomes.
documentation method in case management that records unexpected events, the cause for the event, actions taken in response to the event, and discharge planning when appropriate
--most likely to be documented when they are affected by quality, care or length of stay.
Computer Based Patient Record Institute
promote universal and effective use of electronic health care info. sys.
CPRI Computer Based Patient Record Institute.
formed to promote the universal and effective use of electronic health care information systems to improve health and the delivery of health care was merged into HIMSS in 2002.
Minimum Data Sets
A standard established by healthcare institutions that specifies the information that must be collected from every patient.
Categories of nursing minimum data set
Nursing care elements(nursing dx and interventions)
Patient demographic elements (sex, DOB, ethnicity)
Service Elements( admission/discharge dates, expected payer of services)
EMR Electronic Medical Record
electronic file where patients health information is stored in a computer system
--can be distributed to many caregivers
--used in comparisions to pt with similar diagnosis
--contribute to research, education and efficiency
Safe Computer Charting
Never give out passwords, don't leave computers, follow protocol for correcting errors, never create/change/delete records unless you have authority, back up files, only use encrypted email, follow procedure for documenting.
similar to credit card with magnetic strip on either side. Hold vital emergency info. Has PIN.
EHR Electronic Health Record
An integration of all medical documentation into electronic format
(computer science) a database that can be accessed by computers
Personal Health record
an electronic, universally available, lifelong resource of health information needed by individuals to make health decisions
Initial nursing assessment
important because it provides a baseline for later comparisons as a patients condition changes.
type of card file that summarizes the persons drugs, treatments, diagnosis, routine care, measurements & special needs
Plan of Nursing Care
written guide that directs the efforts of nursing team as the nurses work with patients to meet health goals, it specified nursing diagnoses, outcomes, and associated nursing interventions
also referred to as integrated care plans, care or clinical maps... this describes a multidisciplinary plan used by all caregivers to tract the Pt's progress
Notes used in the patient chart to track the progress and condition of the patient.
record frequent measurements and activities of daily living, eg food intake, activities done, ADL done, BM
records measurements and observations made daily, every shift or 3-4x a day eg weight, Dr visits, BP temp
24 hour fluid balance record
used to document the I & O of fluids for a pt with special needs
A file maintained on hospital units that documents the schedule and dosing of medications given to patients
allow nurses to rank pts as high to low acuity in relation to pts condition and need for nursing assistance or intervention
--also used in conjunction with 24 hour patient care records.
Part of a patient's medical record. It is a comprehensive outline of the patient's entire hospital stay. It includes condition at time of admission, admitting diagnosis, test results, treatments and patient's response, final diagnosis, and follow-up plans.
Home Healthcare Documentation
Sent to attending physician for signed orders.
Ensures continuity of care
Sent to third party payers.
Outcome and Assessment Information Set
Collects information related to Sociodemographic characteristics, envioronmental factors, Social suport, Health status, Functional status; Includes and ADL/IADL section and prior and current functional status for each item
--core items of comprehensive assessment for adult home care.
Home Health Agencies
provide skilled sursing services, physical therapy, OT, social work and speech services, medicare, private pay or reimbursement, home medical equipment
Resident Assessment Instrument
Long term documentation, helps staff gather definitive information on a residents strengths and needs and addresses individualized plan of care.
Resident Assessment Instrument contains basic components
Minimum Data set, Triggers, resident assessment protocols, Utilization guidelines.
Minimum data set
A report that focuses on the degree of of assistance or skilled care that each resident of a long-term care facility needs
Indications that a risk has occurred or is about to occur. These may be discovered in the risk identification process and watched in the risk monitoring and control process. Sometimes called risk symptoms or warning signs. *Conditions that cause a risk.
Resident Assessment protocols
Guidelines that help nurses develop a care plan for a long-term care resident. Required by OBRA
Specified in state operation manuals that instruct when and how to use the RAI
oral, written or computer based communication of patient data to others.
Communication/Documentation Situation, Background, Assessment, Recommendation
Methods of communicating between healthcare professionals
face to face, telephone, written message, audiotape, computer.
change of shift reports
whether written, oral and taped are not part of the legal health record; they are a means of communicating client info that may or may not be included in the health record; they are important of continuity of care.
WRITTEN DOCUMENT THAT IS FILLED OUT WHEN ANY UNEXPECTED SITUATION OCCURS THAT CAN CAUSE HARM TO A PATIENT, EMPLOYEE, OR ANY OTHER PERSON
to consult, talk over, exchange opinions over patient care
process of inviting another professional to evaluate the patient and make recommendations to you about his/her treatment.
process of sending or guiding the patient to another source for assistance
Nursing care conference
formal meeting of nurses to discuss some aspect of patient's care
Nursing Care Rounds
they are procedures in which a group of nurse visit selected patients individually at each patient's bedside
nursing specialty integrating nursing science, computer science, and information science in identifying, collecting, processing, and managing information to support nursing practice, administration, education, research, and the expansion of knowledge.
wireless handsfree voice recognition documentation and communication system for infusion nurses
Small badge worn on nurse controlled using hands free instant 2 way voice conversation.