Informatics and Documentation
Chapter 9 Reading pp142-163
Terms in this set (49)
What is the definition of documentation?
Anything written or printed within a patient record, which may be either paper, electronic, or a combination.
What is the purpose of a patient record?
It provides evidence for credentialing, research, and reimbursement, as well as providing a database for planning health care.
What does a nurse need to know about Confidentiality?
Do not disclose information about patient's status to other patients, family members (unless granted by the patient) or to health care staff not involved in their care.
What is HIPPA and what is it's purpose?
Health Insurance Portability and Accountability Act. The legislation governs all areas of health information management, including reimbursement, medical record coding, security, and patient record management.
Can a student nurse review a medical record in a clinical setting?
You can review the record only for information needed to provide safe and efficient care. NEVER access the medical records of other patients on the specific clinical care area.
What are some of the things a student nurse should do to protect patient privacy?
Make sure that written materials you use in clinical practice do not have patient identifiers, such as room number, DOB, medical record numbers, etc.
What is the NCQA?
The National Committee for Quality Assurance. Your documentation needs to conform to their standards. This is important for institutional accredidation and to minimize liability.
What is a patient record/chart?
A confidential, permanent legal document of information relevant to that patient's health care. (see pg 144 for what the chart contains)
What qualifies as a report?
Reports are oral, written, or audiotaped exchanges of information between members of the health care team. Common reports are change-of-shift, telephone, transfer, and incident.
What is the ONLY permanent record documenting patient care from admission to discharge?
The medical record. (Not to be confused with the patient record.)
What is one of the best defenses for legal claims associated with health care?
Legal Guildelines for Recording
-Do not erase, apply correction fluid, or scratch out errors made while recording
-Do not write retaliatory or critical comments about patient care by other health care professionals
-Add additional information to an existing entry by writting the date and time of the new entry and include "addendum to the note of (date)
-Correct all errors promptly
-Recorde all facts
-Do not leave blank spaces in nurses notes
-Recorde all entries legibly in black ink
-If order is questioned, record that clarification was sought
-Chart only for yourself
FOR A COMPLETE LIST see page 145.
What is a DRG?
Diagnosis-related groups. They are the basis for establishing reimbursment for patient care.
What are the 6 purposes of records?
-Auditing and Monitoring
What are the Guildlines for Quality documentation and reporting?
What is a POMR?
It's a structured method of documentaton that emphasizes the patient's problems. It has the following major sections; database, problem list, initial care plan, discharge summary, and progress notes.
What are progress notes?
Team members use progress notes to monitor and recorde the progress of a patients problems. Types: narrative notes, flow sheets, disharge summaries, and structured notes.
What is a SOAP note?
One format for entering a progress note that uses
(Sometimes an I and E are added to make SOAPIE I- intervention E-Evaluation)
What is a PIE note?
The PIE note documentation format is similar to SOAP but it differs from the SOAP method in the PIE charding has nursing origins whereas SOAP originated from a medical model. PIE=
P-Problem or nursing diagnosis
I-Interventions or actions taken
E-Evaluation of the outcomes of nusing interventions
What is Focus Charting?
A unique narrative format in that it places less emphasis on patient problems and instead focuses on patient concerns such as a sign or symptom, a condition, behavior, or a significant event.
What is CBE?
Charting By Exception. An innovative approach to reduce the time required to complete documentation. In a CBE system an agency defines crteria for nursing assessments and standards of practice for nursing interventions. Thus, CBE syply involves completing a flow sheet that incorporates those standard assessment criteria and interventions.
What is a Case Management Plan/Critical Pathway?
It's a plan of delivering care that uses multi-disciplinar approach to documenting patient care and focuses on providing quality care in a cost-effective manner. They are usually organized according to categories such as activity, diet, treatments, protocols, and discharge planning. Also called care maps or care paths.
What is a variance?
A deviation or detour from the plan's pathway and they refer to either a negative or positive change, depending on the situation. (IE- patient progresses through PT faster, or patient does not meet the expected outcomes).
What is the purpose of an Admission Nursing History form?
To provide a baseline date for later comparisions with changes in the patients condition.
What are flow sheets and Graphic records?
They allow documentation of certain routine observations or specific measurments made repeatedly, such as height and weight, activities of daily living, vital signs, pain assessment, and intake and output. (Visual.)
What is a Kardex?
It's a flip-over card file kept at the nuses' station that provides information for the daily care of a patient.
Acuity Recording is..?
A system that determines the hours of care for a nursing unity and the number of staff requiered to care for a given group of patients.
What is a Standardized Care Plan?
Some institutions use them to make documentation more efficient. After completing a nursing assessment, place the appropriate standard of care plans in your patient's record.
What is a hand-off report?
One that happens any time one health care prrovider transfers care of a patient to another HCP.
A change of shift report is...?
A type of hand-off-report that occures at the end of each shift.
What are walking rounds?
A change-of-shift report where nurses will walk with each other from one patients room to the next.
What is a transfer report?
Another type of hand-off-report that involves communication of information about patients from the nurse on the sending unit to the nurse on the receiving unit. Usually given by phone or in person.
When would an RN make a telephone report?
When significant events or changes in a patient's condition have occured.
What is the SBAR guideline for telephone reports?
Situation-Background-Assessment-Recommendations. A telephone report needs to include clear, accurate, and concise information.
What is a TO? What is a VO? What are the rules regarding them?
Telephone Order/Verbal Order. The person receiving the order must write down the complete order or enter it into a computer as it is being given. Then the nurse must read it back, called 'read-back' and receive confirmation from the person who gave the order.
What is an Incident/Occurance report?
Used when there is an actual or potential injury; this report is not part of the patient record.
What is the definition of Informatics?
It's the science and art of turning date into information. Informatics focuses on information and knowledge acquisition, rather than the tool, the computer.
What is IT?
Information Technolofy. The management and processing of information, generally with the assistance of computers.
What is an HIS?
Healthcare information system. A group of systems withing a health care enterprise that support and enchance health care. Two major types: Clinical and Administrative.
What is a NIS?
Nursing Information System. Used to support the documentation of nursing process activities and offer resources for managing nursing care delivery.
What is Nursing Informatics?
A nursing specialty that manages and communicates data, information, knowledge, and wisdom by integrating nursing, computer, and information science.
What are the benifits of a NIS?
Improved quality, reduced errors of omission, reduced hospital costs, increased job satisfaction, compliance with accrediting agency mandates, etc.
What are the downfalls to NIS?
What are the three aspects of data security?
1-Ensuring accuracy of data
2-Protection of date from unauthorized eyes inside or outside of the agency
3-Protection from data loss
What is a firewall?
A combination of hardware and software that protects private network resources from outside hackers, network damage, theft, or misues.
What is the handling procedure regarding faxes?
-Confirm the fax numbers are correct before sending
-Use a cover sheet
-Authenticate both ends of the transmission
-Use a programmed speed-dial to eliminate the change of wrong numbers
-Place fax machines in a secure area
-Limite machine access
-Log fax transmissions
What is CPOE?
Computer provider order entry. An ordering system that is gaining popularity in large medical centers. Includes reduced use of resources, reduced lenth of stay, and overall reductions in costs.
What is an EHR?
Electronic Health Record. A logitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Decreases the amount of time spent waiting for information while a patient is in one location and a chart is in another location.
What are the ANA's guidlines for safe computer charting?
1-Do not share your password
2-Avoid leaving the computer terminal unattended while logged in
3-Follow the correct protocol for correcting errors according to agency policy.
4-Software systems hae a sstem for backup files.
5-Avoid leaving information about a partient displayed on the monitor.
6-Follow your agency's confidentiality procedures for documenting sensitive material, such as AIDS.
7-Protection of printouts from computerized records is important. Shred printouts/log number of copies.