Yoost Chapter 10: Documentation, electronic health records and reporting

APIE
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Terms in this set (20)
APIE
Assessment
Problem
Intervention
Evaluation
MAR
Medication administration record
EHR
Electronic Health Record
SBAR
Situation
Background
Assessment
Recommendation
HIPPA
Health insurance portability and accountability act
BCMA
Bar-coded medication adminstration
POMR
Problem oriented medication record
Documentation
Purpose it to facilitate the flow of information that supports continuity, quality and safety of care
Guidelines of documentation
- accessible, accurate, timely, clear, concise, complete and objective
- non-judgemental and factual
- Should be written in order of how events happened
- should occur as soon as possible after event
- Every entry should include date, time, and signature with credentials
Paper Records
Advantage: no special tech training is necessary

Disadvantages: difficult to locate, available to one person at a time, fragile, susceptible to damage and can degrade over time. Handwriting may be hard to read and storage and control can be an issue.
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