Yoost Chapter 10: Documentation, electronic health records and reporting

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Electronic RecordsAdvantage: major cost savings, gains in productivity, reduction of errors, improvement in health status, better monitoring, reduce storage space, allow access to multiple users, easy duplication for sharing or backup, increase portability. Disadvantage:special training is needed, concern over privacy, cost of installation and possible failure with power loses.Major Components of the EHR- health information - diagnostic test results - an order-entry system - decision supportPoint of Care Documentationdone at pt bedside with a mobile computer station or handheld deviceCharting by ExceptionRecords only abnormal or significant data by assuming certain norms. This reduces charting time. Each facility must decide what is normal.Admission SummaryIncludes: pt history, med reconciliation, initial assessment, address pt problem, identify needs (either discharge planning or formulation of a plan of care)Discharge SummaryAddresses the pt hospital course, plans for follow up, pt status at discharge, pt education on medication/treatment, discharge placement, follow-up apts, and referrals.Uses for protected health care informationtreatment, payment, or health care operationsANTICipateAdministrative data New clinical info to be updated Tasks to be performed Illness severity ContingencyVerbal Ordermust be taken by a RN repeat order back verbatim enter into system and document as a verbal order include date, time, physician name and RN signatureIncident Reportused when an unusual or unexpected event regarding a pt happens ex: fall, med error, or equip malfunction purpose is to document the details immediately to ensure accuracy