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39 terms

Documentation

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