Fundamentals of Nursing Taylor Ch 16 Documenting

Terms in this set (44)

change of shift report
communication method used by nursed who are completing are for a patient to transmit patient information to nurses who are about to assume responsibility for continuing care, may be exchanged verbally in a meeting or audiotaped.
charting by exception (CBE)
shorthand method for documenting patient data that is based on well defined standards of practice, only exceptions to these standards are documented in narrative notes.
Critical/collaborative pathway
- A case management plan that is a detailed, standardized plan of care developed for a pt population with a designated Dx or procedure.
- It includes expected outcomes, a list of interventions to be performed, & the sequence & timing of those interventions.
- Defined goals for each day so can see where pt is in their progress.
confer
To consult with someone to exchange ideas or to seek information, advice or instructions.
consultation
Process in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution.
critical thinking
thought that is disciplined, comprehensive, based on intellectual standards and as a result, well reasoned. a systematic way to form and shape one's thinking and functions purposefully and exactingly.
discharge summary
description of where the patient stands in relation to problems identified in the record at discharge, document any special teaching or counseling the patient received including referrals.
documentation
written, legal record or all pertinent interventions with the patient - assessments, diagnoses, plans, interventions and evaluations.
Electronic health record (EHR)
- Computer based records or data that can be distributed among many caregivers in a standardized format, allowing them to compare & uniformly evaluate pt progress easily.
- Agencies under different ownership share pt data. Goal is for it to be nationwide.
Electronic medical record (EMR)
Electronic patient record created by agencies of common ownership. Data is not shared outside of the one hospital ownership.
flow sheet
graphic record of abbreviated aspects of patient's condition.
focus charting
a documentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care. The focus may be a patient strength or a problem or need. The narrative portion of focus charting uses the data, action and response format.
Graphic sheet
Form used to record specific patient variables, such as pulse, resp rate, BP, temp, wt, I/O, BM.
Hand-off
A nurse's report to another nurse or provider about a patient's status & progress.
Health Information Exchange (HIE)
An organization that provides services to enable the electronic sharing of health-related info. Improves quality & safety of pt care.
incident/variance 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.
Meaningful use
- The use of certified electronic health record technology to achieve health & efficiency goals, with a financial incentive from Medicare & Medicaid.
- Goal is pt centered, evidence-based, prevention-oriented, efficient, & equitable care.
minimum data set
- A standard established by healthcare institutions that specifies the info that must be collected from every patient.
- Forms the foundation of the comprehensive assessment of all residents in long-term care certified by CMS.
- The items included in the data set standardize communication about pt problems/ conditions.
narrative notes
progress notes written by nurses in a source oriented record.
nursing informatics
specialty that integrates nursing science, computer science and the information science to manage and communicate data, information and knowledge in nursing practice.
Occurrence/variance charting
- Documentation when a pt fails to meet an expected outcome or a planned intervention is not implemented, including the unexpected event, the cause of the event, actions taken in response to the event, & DC planning when appropriate.
- Typically used for variances that affect quality, cost, or length of stay.
OASIS
outcome and assessment information set. assessment instrument representing core items of a comprehensive assessment for adult non-maternity home care patients and forms the basis of measuring patient outcomes for the purpose of improving the quality of care that is provided.
patient record
a compilation of a patient's health information, the patient record is the only permanent legal document that details the nurse's interactions with the patient.
personal health record (PHR)
information sheets that contain the individuals medical history, including diagnoses, symptoms and medications.
PIE charting
documentation system that does not develop a separate care plan, the care plan is incorporated into the progress notes in which problems are identifies by number, worked up using the problem, intervention, evaluation format and evaluated each shift.
problem oriented medical record (POMR)
Documentation system organized according to the person's specific health problems, includes database, problem list, plan of care and progress note.
Read back
A process in which a nurse or other healthcare provider repeats a verbal order back to the physician to ensure that it was correctly heard and interpreted.
progress notes
any of a variety of methods of notes that related how a patient is progressing toward expected outcomes.
SBAR communication




ISBARR
-Consistent, clear, structures and easy to use method of communication between healthcare personnel, it organizes communication by the categories: Situation, Background, Assessment, and Recommendation.
- Identity/Introduction, Situation, Background, Assessment, Recommendation, Read back
SOAP format



SOAPIER
- Method of charting narrative progress notes, organized data according to subjective information: Subjective data, Objective data, Assessment, and Plan.
- Used to organize a written note, usually in POMR (Problem-oriented medical records).
- Subjective data, Objective data, Assessment, Plan, Intervention, Evaluation, Response
referral
process of sending or guiding someone to another source for assistance.
source oriented record
documentation system in which each healthcare group records data on its own separate form.
Variance report/Incident report/Occurrence report
- A report of any event that is not consistent with the routine operation of the health care agency that results in or has the potential to result in harm to a pt, employee, or visitor.
- Used for quality improvement, not discipline.
Characteristics of efficient documentation
- Consistent with professional standards
- Complete
- Accurate
- Concise
- Factual
- Organized and timely
- Legally prudent
- Confidential
What is confidential?
All information about patients written on paper, spoken aloud, saved on computer
- Name, address, phone, fax, social security
- Reason person is sick
- Treatments patient receives
- Information about past health conditions
Patient rights
- To see and copy their health record
- Update their health record
- Get a list of disclosures
- Request a restriction on certain uses or disclosures
- Choose how to receive health information
Purpose of patient records
- Communication among healthcare professionals = primary purpose of pt record
- Recording diagnostic and therapeutic orders
- Care planning
- Quality Process & Performance Improvement
- Credentialing
- Legal and historical documentation
- Reinbursement
Benefits of Nursing informatics
- Increases in the accuracy and completeness of nursing documentation
- Improvement in the nurse's workflow and a elimination of redundant documentation
- Automation of the collection and reuse of nursing data
- Facilitation of the analysis of clinical data
Nursing documentation
Inital nursing assessment
Care Plan
Patient Care Summary
Critical/Collaborative Pathways
Progress Notes
Flow Sheets & Graphic Records
Medication Record
Acuity Records - rank pts in order of sickest
Discharge and transfer summary
Documentation ABC's
A - Accurate
B - Bias Free
C - Complete
D - Detailed
E - Easy to read
F - Factual
G - Grammatically correct
H - Harmless (legally)
What to document
Any significant event or changes in pt's condition
Informed consent
Patient teachings
Attempts to contact PCP
Patient leaving AMA - against medical advice
Patient refusal of treatment
Use of restraints
Occurrences
Interventions, responses, evaluation of goals
***if not documented...it never happened
Methods of reporting
Bedside
Face to face oral
Telephone conversations
Written messages
Computer messages
Audio-recorded messages
Documentation Guidelines
1. Content - avoid generalizations, complete, accurate, concise, factual, reflects nursing process, legally prudent manner
2. Timing - military, be timely, don't doc beforehand; doc at admit, transfer, dc, after procedure, change in status, Dr. communication
3. Format - use standard terminology, date & time, chronological order, paper or EMR
4. Accountability - Signature , correct errors, remember the record is permanent
5. Confidentiality- breaches include discussions, computers, social media, HIPAA, copying data
Documentation Methods
1. Computerized EHRs
2. Source-Oriented = Diff section for ea discipline, chronological, progress & narrative notes, paper
3. Problem-Oriented = Organized based on problem; includes defined database, problem list, care plans, progress notes (SOAP); paper format
4. PIE charting = Problem, Intervention, Eval
5. Focus charting = DAR (Data, Action, Response)
6. Chart by exception = Review parameters & check yes/no, skip something = normal parameters, trend with computers
7. Case Management Model = collaborative or critical pathways/care paths/care maps
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