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Documentation P & A

Terms in this set (80)

Sentinel event
an unexpected occurrence involving death or serious physical or psychological injury
Purposes of the Medical Record
-Communication
-Assessment
-Care Planning
-Legal Document
-Quality Insurance
-Reimbursement
-Research
-Educaiton
Who can see the medical record?
Directly involved in care, including;
-HCP
-Nurse
-Technicians
-Therapists
-Social Workers
-Client advocates
-Admin (for stat analysis, staffing and quality care)
*Others must receive permission
Using the medical record for research
ANy information provided by the client is not to be reported in any manner that identifies them, and is not to be made accessible to anyone outside the research team
Audit
is a review records
eMAR
Electronic medication administration record- interfaces medication orders with pharmacy dispensing and allows direct computer charting of medication administration
CPOE
Computerized physician order entry -allows authorized providers to enter all orders directly into the computer, electronically communicating orders to the laboratory, pharmacy, and nursing personnel
Benefits of the EHR
-allow several health team members to view the patient record simultaneously.
-Those with special clearance may view the EHR off-site to note changes in patient condition or to order necessary laboratory tests, diagnostic studies, or medications.
-Computerization ensures that all entries are legible and time dated.
-It enables the graphing of trends in vital signs or assessment data.
-It minimizes compliance issues because programs will not let nurses enter data until they have completed all required fields. T.
-Some programs create plans of care from entered assessment data.
-Confidential access
Principles of Documentation
CONFIDENTIAL
ACCURATE
CONCISE AND COMPLETE
OBJECTIVE-
ORGANIZED AND TIMELY-
Benefits of CPR
-computer-based personal record
- increased accessibility beyond the primary institution.
-uniform access to a single patient record, allowing greater accuracy and improved care. \ -
-allowing patients to share complete health information with any practitioner, regardless of institutional affiliation or time and place when care was originally provided.
CONFIDENTIAL-
Nurses are required legally and ethically to keep all information in the patient record confidential.
Confidentiality means keeping information private. All patient information is confidential and discussed only with other healthcare professionals directly involved in the patient's care
The Health Insurance Portability and Accountability Act (HIPAA) that gives patients greater control over their medical records became effective in 2003. HIPAA regulates all areas of information management, including reimbursement, coding, and security of records
ACCURATE-
Entries must be accurate. Nurses must chart only observations that they have seen, heard, smelled, or felt. An observation made by another health professional must be clearly identified as such. Precise measurements and times must be used whenever possible. For example, a wound should be described as "3 cm by 0.5 cm," rather than "small."
CONCISE AND COMPLETE-
Good charting is concise and brief, yet complete. Most EHR do not let nurses enter data until all required fields have been completed. In narratives, use partial sentences and phrases; drop the patient's name and terms referring to the patient. Use abbreviations but only those that are commonly accepted and approved by your facility
Objective Charting
When charting subjective findings, make every effort to identify the source and context for the finding. This point is particularly important when recording information about psychosocial and mental health issues. Directly quoting statements made by the patient can help maintain objectivity.
most common cause sentinel events:
communication
-
...
When does an incident report need to be made?
- Accidental omission of prescribed therapies
-Cirumstances that led to an injury
-Circumstances that put client at risk of injury
-Medication admisistration errors
-Needle-stick injuries
-Procedure related or equipment related accidents
Nursing Progress Notes
are recorded for all patients but vary in format depending on the agency and setting.
-They reflect a specific problem being addressed or the care provided over a specific period. Narrative notes, SOAP notes, DAR notes, and PIE notes are all descriptive forms of documentation that summarize nursing assessments, interventions, and patient responses
TeamSTEPPS
Team Strategies and Tools to Enhance Performance and Patient Safety
focuses on 4 core skills of TeamSTEPPS:
leadership, situation monitoring, mutual support, communication
SBAR Perks
provides a framework for team members to effectively communicate information to one another
short and concise
SBAR
Situation
Background
Assessment
Recommendation
Handoff
the transferring of information during transitions of patient care
the primary object of a handoff is to provide accurate information about a patient's care, treatment and services, current condition, and any recent anticipated changes
I PASS the BATON
Introduction - introduce yourself and your role
Patient - Name, identifiers, age, sex, location
Assessment - chief complaint, vital signs, symptoms, diagnosis
Situation - current status (code status, recent changes, response to treatment
Safety Concerns - critical lab values, socio-economic factors, allergies, alerts
Background - comorbidities, previous episodes, current med, family history
Actions - actions taken or required; provide brief rationale
Timing - level of urgency, explicit timing, prioritization of action
Ownership - who is responsible (include pt/family responsibilities)
Next - what will happen next?, anticipated changes, plan
Charting by Exception
...
The nurse's role to carry out HCP's presciptions
The nurse is obligated to carry out an prescription EXCEPT when the nurse believes a prescription to be inappropriate or inaccurate.
-The nurse that does carry out an erroneous prescription may be legally responsible
Patient Self-Determination Act
is a law that indicates clients must be provided with information about their rights to identify written directions about the care that they wish to receive in the event that they become incapacitated and are unable to make healthcare decisions
Instructional directives
lists the medical treatment that a client chooses to omit or refuse if the client becomes unable to make decisions and is terminally ill
Power of Attorney
Appoints a person as a health care proxy chosen by the client to make healthcare decisions on the client's behalf when the client can no longer make the decisions
Nurses role in advance directives
-Discussion options with client opens the communication channel to establish what is important to the client and what the client may view as promoting life vs prolonging death.
-Needs to ensure the pt has been provided with information about their rights to advance directives
-On admissions the nurse determines if AD exist and are in the medical record
-Insures the HCP knows the wishes of the cleint
-Insure that the pt wishes are followed
Reporting responsiblities
-Child/elder abuse
-domestic violence
-dog bite/animal bite
-gunshot/stab wounds
-assaults
-homicides
-suicides
Call-Out
-a strategy used to communicate important or critical information-informs all team members simultaneously during emergency situations
-helps team members anticipate the next steps-division of responsibilities
Focus
D- Data
A-Action
R-Response
Advantages of a Focus DAR
Broad view permitting charting on any significant area, not just problems; concise, flexible; works well in long-term or ambulatory care
Disadvantages of Focus
Not multidisciplinary; difficult to identify chronologic order; progress notes may not relate to the care plan.
Check-Back
uses closed-loop communication to ensure that information conveyed by the sender is understood by the receiver as intended
1) sender initiates the message
2) receiver double-checks to ensure that the message was received
3) sender double-checks to ensure the message was received i.e. Doctor: Give 25 mg Benadryl IV push. Nurse: 25 mg Benadryl IV push?
Doctor: That's correct
Audit of Records
Dual purpose. 1st is quality assurance 2nd is Reimbursement
Never Events
-foreign object left in patient after surgery
-air emboli
-infusion with incompatible blood
-Falls resulting in trauma
-Catheter associated infections
-Pressure Ulcers
HIPAA
Health Insurance Portability and Accountability Act that gives patients greater control over their medical records
Point of Care Documentation
POC- documenting that takes place as care occurs. Promotes efficiency, accuracy and timeliness
Batch Charting
Waiting to the end of the shift to record events on several patients; may cause nurse to omit important date of enter inaccurate information
Flow Sheets
Are tables that have vertical columns to allow nurse to document and compare routine procedures, like vitals
Charting by Exception
CBE- permits nurse to document only those findings that fall outside of standard values.
-Standards met—sign or check off; standards not met—write narrative or SOAP note
CBE advantages
-Efficient; use of flow sheets permitting rapid detection of changes in condition; outline normal assessments; can take -the place of plan of care
Requires less time, easy to ID patient status, but will not protect nurse if there are legal challenges. "If it isn't charted, it did not happen"
CBE disadvantages
Expensive to institute; in-servicing of staff is needed; not prevention focused; not appropriate for long-term or ambulatory care
Narrative Nursing Notes
Information provided in written sentences or phrases; usually time sequenced
SOAP
subjective
objective
assessment
plan
Focuses on one problem
Plan of care is incorporated and outcomes included
SOAP Advantages
All charting focuses on identified patient problems; interdisciplinary—all team members can chart on the same progress notes; easy to track progress for identified problem; steps in the nursing process are mirrored.
SOAP Disadvantages
Difficult to master. Specific focus makes it difficult to chart general information without identifying a problem; lengthy and time-consuming; assessment identification difficult for nurses and confusing, because assessment data are provided in S and O.
what are the documentation standards
variety of organizations that govern nursing documentation standards. federal and state regulations accrediting agencies - need specifics standards of documentation in order to be met reimbursement requirements too
documentation
record or proof of care that has been provided to a person.contained in the medical record Is considered a valuable source -all healthcare team members can access it communication of what type of care that was provided.
medical record
as a communication tool reduces errors (patient progress, care provided, accurate and up to date movement towards EMR was mandated in 2014
purpose of the medical record
legal documentation- permanent record provide information of the status of the information and tell the care done can protect against a legal claim - if done accurately and complete if incomplete - can open up the institution or individuals to liability if its not documented its considered not done.
assessment data
reflects status / progress of patient data you will input data and trend data from previous individuals look back and see status of patient
care plan
individualized to that patient to coordinate that care so that we can move and achieve the goals of the patient
quality improvement
regular audits of the medical record, determine if the standards of care being met and where to improve quality.
reimbursement
your documentation helps the agency to become reimbursed medicare, medicaid, workers compensation and third party -insurance companies usually require specific criteria to be met to cover specific health related expenses. your documentation clarifies the type of treatment a patient receives and supports reimbursement to the health care agency.
NEVER EVENTS -
in 2008 medicare and medicade stopped reimbursing hospitals for what they considered hospital acquired complications that were preventable such as pressure ulcers, clab c cautis.
research
chart reviews are completed for research studies ,these types of research studies still require approval by the agency even though they look at specified parts.
education
also for the purpose of teaching - when rounds are conducted, to teach students the nature of an illness and a patients response to this.
organized documentation
each entry must show a logical and systematic grouping of important information of problem or occurrence
legal guidelines that help prevent malpractice or neglegant claims
-correct all errors, record all facts, do not leave blank spaces
-write legibly
-if order was questioned, record that clarification was sought
-chart only for yourself
-avoid generalizations
-begin each entry with the date and-time and end with your signature and title
-keep your computer password secure.
nursing progress notes
-reflect a specific problem being addressed or care provided over a specific amount of time
narrative notes
- written in paragraph or narrative form ( time consuming / hard to find imformation looking for)
SOAP
- subjective objective assessment plan
SOAPIE
- includes intervention and evaluation
PIE
- talk about problem
- problem,
-intervention,
-evaluation
Focus charting (DAR)
focus charting method , problem area or nursing diagnosis. go to that list and see the problem areas of their patient.
I PASS BATON
template used when provided some type of a patient hand off
I- introduction-
introduce yourself and the patient
P-
patient name and identifiers
A- assessment:
chief complaint, vital signs, symptoms, diagnosis
S- situation -
current status, code status, response to treatment
S- safety:
critical labs, allergies, falls risk, isolation precaustions
B- background
- co morbidities, family history, previous episodes
A- actions:
what actions were taken or are required
T- timing:
level of urgency, prioritize actions
O- ownership:
who is responsible (nurse/doctor/team)
N- next ;
what will happen next ? what is the plan?
incident/ occurrence report
completed when there is any usual happening to a patient or an employee
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