Upgrade to remove ads
Only $35.99/year

Taylor Fundamentals of Nursing Chapter 16: Documenting, Reporting, Conferring + Using Informatics

Terms in this set (31)

Documentation
Written or electronic legal record of ALL pertinent interactions with the patient (ADPIE):
- Assessing
- Diagnosing
- Planning
- Implementing
- Evaluating
Patient Record
Is a compilation of a patient's health information.
3 Instances where patient authorization is NOT required prier to releasing a patient's information
1.) PUBLIC HEALTH ACTIVITIES

2.) LAW ENFORCEMENT + JUDICIAL PROCEEDINGS

3.) DECEASED PEOPLE
7 Acceptable Situations of Incidental Disclosure of PHI
1.) Use of sign in sheets
2.) Possibility of a confidential conversation being overheard
3.) Placing patient charts outside exam rooms
4.) Use of white boards
5.) X-ray light boards that can be seen by passers by
6.) Calling out names in waiting room
7.) Leaving appointment reminder voicemail messages
Verbal Orders
- ONLY in emergency situations in which the physician or nurse practitioner is present but finds it IMPOSSIBLE to write the order
- The order must be given directly to those who will execute the order + must be "READ-BACK" + later documented
Read-Back
During an emergency situation in which Verbal Orders are given, the verbal order must be READ BACK to the authority who gave to order to ensure accuracy
Personal Health Records (PHR) + 2 types
- An online system that organizes personal health records
- Contains person's medical history, including diagnoses, symptoms + medications
- They may give health care professionals their password so that they can log on + may give permission to share with family members

Two types:
1.) STANDALONE PHR: patients fill in their own records + information is stored on patients own computers or the internet. Sometimes can accept data from external sources. Patients can add diet or exercise information

2.) TETHERED/CONNECTED PHR: Is linked to a specific health care organization's electronic health record system. Patients can access their own records through a secure portal + see the trend of their lab results over the last year, immunization history or due dates for screenings
Health Information Exchange (HIE)
Allows doctors, nurses, pharmacists + other health care providers + patients to appropriately access + securely share a patient's vital medical information electronically- improving the speed, quality, safety + cost of patient care
Source Oriented Record
A paper format in which each health car group keeps data on its own separate form
- Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, etc.
- Notations are entered chronologically, with the most recent being nearest the front
- An advantage is that each discipline can easily find + chart pertinent data
- The disadvantage is fragmentation
- Include PROGRESS NOTES + NARRATIVE NOTES
Progress Notes + Narrative Notes
- Both a type of SOURCE ORIENTED RECORD

PROGRESS NOTES: Notes written to inform caregivers of the progress a patient is making toward achieving expected outcomes

NARRATIVE NOTES: Progress notes written by nurses in a source-oriented record. Include a description of the status for the problem, related nursing interventions, patient responses + needed revisions to the plan of care
Problem-Oriented Medical Record (POMR)
- A type of paper record originated by Dr. Lawrence Weed in the 1960s
- Is organized around a patient's problems rather than around sources of information
- All health professionals record information onto the same forms
- Advantages are that the entire health care team works together in identifying a master list of patient problems + contributes collaboratively to plan the care.
-Clearly focus on patient problems
- The "SOAP Format" is used to organize progress notes
SOAP Format
Subjective data
Objective data
Assessment
Plan

- Used to organized progress notes of the POMR
- Some believe that it too narrowly focuses on problems + advocate instead a return to the narrative format
- Variations include: SOAPE, SOAPIE, SOAPIER
- Originated from MEDICAL RECORD
PIE Charting
Problem
Intervention
Evaluation

- Unique in that it does NOT develop a separate plan of care as its plan of care is INCORPORATED into the progress notes
- Identifies problems by number
- A patient's assessment is performed + documented in the progress notes using the PIE method + evaluated each shift
- Resolved problems are dropped from daily documentation following the nurse's review
- Continuing problems are documented + numbered each day
- An advantage is that it provides CONTINUITY of care + saves time as there is NO separate plan of care
- A disadvantage is not having a formal plan of care + nurses will need to read all the nursing notes to determine problems + planned interventions before initiating care
- PIE format has a NURSING origin
Focus Charting
- Is to bring the focus of care back to the patient + the patient's concerns.
- Instead of a problem list or list of nursing or medical diagnoses, a FOCUS COLUMN is used that incorporates many aspects of a patient + patient care
- The focus might be a patient strength, problem or need
- Topics that appear in the FOCUS COLUMN include patient concerns + behaviors, therapies + responses, changes of condition + significant events such as teaching, consultations, monitoring, management of activities of daily living or assessment of functional health patterns
- The NARRATIVE PORTION focuses on using the Data, Action, Response (DAR) format
- An advantage is the holistic emphasis on the patient + the patient's priorities + ease of charting
- Some see the DAR categories as artificial + not helpful when documenting care
DAR format
Data
Action
Response

- Format of the narrative portion of FOCUS charting
Charting By Exception (CBE)
- A 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
- Benefits include less time needed for charting, a greater emphasis on significant data, timely bedside charting, standardized assessment, greater interdisciplinary communication, better tracking of important patient responses + lower costs
- Drawbacks include is its limited usefulness when trying to prove that high-quality safe care was given if a negligence claim is made
2 Examples of Case Management Model
1.) Collaborative Pathways
2.) Occurrence Charting
Collaborative Pathways
- Part of the CASE MANAGEMENT MODEL
- SPECIFIES the plan of care LINKED to EXPECTED OUTCOMES along a TIMELINE
- Commonly linked to computerized documentation system
- Charting By Exception is frequently used
Occurrence (Variance) Charting
- Part of the CASE MANAGEMENT MODEL
- Also called VARIANCE CHARTING
- Used when a patient fials to meet an expected outcome or a planned intervention is not implemented in the case management model
- Charting of an expected event, the cause of the event, actions taken inresponse to the event + discharge planning
- The variances most likely to be documented are those that affect quality, cost or length of stay
Graphic Record
A form used ot record specific patient variables such as: PULSE, RESPIRATORY RATE, BLOOD PRESSURE, BODY TEMPERATURE, WEIGHT, FLUID INTAKE / OUTPUT, BOWEL MOVEMNTS, etc
Discharge Summary
Should be written whenever a patient is discharged from care or transferred from one unit, institution or agency to another
- Concisely summarizes the reason for treatment, significant findings, the procedures performed + treatment rendered, the patient's condition on discharge or transfer + any specific pertinent instructions given to patient + family
OASIS
- Outcome + AsseSsment Information Set
- Used by Home Health Care documentation
- A group of data elements that represent core items of a comprehensive assessment for an adult home care patient
- Form a basis for measuring patient outcomes for purposes of outcome-based quality improvement (OBQI)
OBQI
- Outcome Based Quality Improvement
- Part of OASIS
RAI + its FOUR basic components
- Resident Assessment Instrument
- Part of Long Term Care documentation
- Helps staff gather definitive information on a resident's strengths + needs + addresses them in an individualized plan of care
- Helps staff keep track of changes in a resident's status
- Goal is to coordinate the efforts of the multidisciplinary team to ensure that residents achieve the highest level of functioning possible

Contains FOUR basic elements:
1.) MINIMUM DATA SET: A core set of screening, clinical + functional status elements that forms the foundation of the comprehensive assessment of all residents that are certified to participate in MEDICARE or MEDICAID. Standardizes communication
2.) TRIGGERS: Specific resident responses for one or a combination of minimum data set elements that identify residents who either have or at risk for developing specific functional problems + who require further evaluation
3.) RESIDENT ASSESSMENT PROTOCOLS: Structured, problem oriented frameworks for organizing minimum data set information + examining additional clinically relevant information about a resident
4.) UTILIZATION GUIDELINES: Specified in state operation manuals that direct when + how to use the RAI
ISBAR communication
Identity / Introduction
Situation
Background
Assessment
Recommendation

- Framework for communication between members of health care team about a patient's condition.
- It is an easy + focused way to set expectation s for what will be communicated + how between members of the team, which is essential for developing teamwork + fostering a culture of patient safety.
Change-of-Shift Report (or Hand-Off)
- Given by a primary nurse to the nurse replacing her
- May be written or given verbally in a meeting or audio or videotaped.
Confer
Is to consult with someone to exchange ideas or seek information, advice or instructions
Consultation
The process of inviting another professional to evaluate the patient + make recommendations to you about the patient's treatment
Referral
The process of sending or guiding the patient to another source for assistance
Nursing Informatics
A specialty that integrates nursing science, computer science + information science to manage + communicate data, information + knowlege in nursing practice
- Facilitates the integration of data, information + knowledge to support patients, nurses + other providers in their decision making in all roles + settings

As more nurses have become informaticists:
- Increases in the accuracy + completeness of documentation
- Improvement of workflow + elimination of redundant documentation
- Automation of the collection + reuse of nursing data
- Facilitation of the analysis of clinical data
Progress notes
In a problem-oriented medical record, the progress notes describe the client's responses to what has been done and revisions to the initial plan. The data base contains initial health information about the client. The problem list consists of a numeric list of the client's health problems. The plan of care identifies methods for solving each identified health problem.
Other sets by this creator