What is the primary purpose of the pt record?
Help healthcare professionals from different disciples communicate with each other
Professional nurses may take orders from
Physicians, dentists, psychologists, podiatrists, and advanced practice nurses . Medical students can only give orders when countersigned by the attending physician, NP, or a house officer assigned to the clinical department
Under what circumstances do telephone orders need to be signed within 24 hours?
When the order is for restraints, narcotics, anticoagulants, and antibiotics
Each healthcare group keeps data on its own separate form. Sections on the record are designated for nurses, physicians, laboratory, x-ray personnel, etc.
Address routine care, normal findings (findings that don't call for changes in the plan of care), and pt problems identified in the plan of care
Problem-Oriented Medical Records (POMR)
Organized around a pt's problems rather than sources of info. All healthcare professionals record info on the same forms. The major parts of the POMR are the defined database, problem list, care plans, and progress notes
Subjective data, objective data, assessment (the caregiver's judgment about the situation), plan. Used to organize data entries in the progress notes of the POMR
Problem, intervention, evaluation. Doesn't develop a separate plan of care. Assessments done every shift and filled out using a flow sheet. Promotes continuity of care, but since it doesn't have a normal care plan nurses have to read all the notes to determine problems and planned interventions before initiating care
Purpose is to bring the focus of care back to the pt and the pt's concerns. Focus might be a pt strength, problem, or need. The narrative portion of focus charting uses the DAR format
Data, action, response. Focuses on holistic emphasis on the pt, but some nurses report the DAR categories are artificial and not helpful when documenting
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
Case Management Model
Promotes collaboration, communication, and teamwork among caregivers; makes efficient use of time; and increases quality by focusing care on carefully developed outcomes. Works best for "typical" pts
Collaborative Pathways (AKA critical pathways)
Used in the case management model. Specifies the plan of care linked to expected outcomes along a timeline. Charting by exception is frequently used with this
When a pt fails to meet an expected outcome or a planned intervention is not implemented in the case management model, this is used. It is the unexpected event, cause of the event, actions taken in response to the event, and discharge planning (when appropriate). The variances most likely to be documented are those that affect quality, cost, or length of stay
Computer-based patient record institution, developed by ANA in response to a recommendation by the Institute of Medicine
The 3 categories of the nursing minimum data set
Nursing care elements (such as nursing diagnoses and interventions), patient demographic elements (such as sex, date of birth, ethnicity), service elements (such as admission and discharge dates and expected payer for services)
Nursing documentation in the pt's permanent record includes the following formats (9)
Initial nursing assessment, Kardex and patient care summary, plan of nursing care, critical/collaborative pathways, progress notes, flow sheets, discharge and transfer summary, home healthcare documentation, and long-term care documentation
Progress Notes (examples)
Narrative nursing notes, SOAP notes, PIE notes, focus charting, charting by exception, and the case management model
Form used to record specific pt variables such as pulse, respiratory rate, blood pressure readings, body temp, weight, fluid intake and output, bowel movements, etc
Concisely summarizes the reason for treatment, significant findings, the procedures performed and treatment rendered, the pt's condition on discharge or transfer, and any specific pertinent instructions given to the pt and family
The Outcome and Assessment Information Set. Group of data elements that represent core items of a comprehensive assessment for an adult home care patient, form the basis for measuring pt outcomes for purposes of outcome-based quality improvement (OBQI). Key component of Medicare's partnership with the home care industry to foster and monitor improved home healthcare outcomes
Resident assessment instrument. Used in long-term care. Helps staff gather definitive info on a resident's strengths and needs, and addresses these in an individualized plan of care.
4 basic components of the RAI
Minimum data set, triggers (specific resident responses for one or a combo of minimum data set elements that identify residents who either have or are at risk for developing specific functional problems and who require further evaluation), resident assessment protocols, utilization guidelines (specified in each state, instruct when and how to use the RAI)
Situation, background, assessment, recommendation. S- communicate what is occurring and why pt is being handed off to another department/unit. B- explain what led up to the current situation and put in context if necessary. A- give your impression of the problem. R- explain what you would do to fix the problem
Incident Reports (aka variance or occurrence reports)
Used to improve the management and treatment of pts by identifying high-risk patterns and initiating in-service programs to prevent future problems. Not used to punish employees!