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Foundations of nursing 6th ed. ch.7 - Documentation
Terms in this set (45)
charting, documenting, recording
recording interventions carried out to meet the pt. needs
documentation is part of:
documentation is necessary for:
evaluation of pt. care
people appointed to examine pt. charts and health records to asses quality of care
legal record that is used to meet the many demands of healthcare, accreditation, medical insurance, and legal systems.
charting by exception: (CBE)
document all pertinent data at the begining of the shift
The accumulated data from the history and physical examination, and diagnostic tests are used to identify and prioritize the health problems on the master medical and other problem lists.
Diagnosis Related Groups (DRG's)
system that classifies pt. by age, diagnosis, surgical procedure using 300 different categories used in predicting the use of hospital resources, including length of stay
-this is the basis for cost reimbursement rates for medicare and medicaid
-Many private insurance companies use similar illness categories when setting hospital payment rates
card system used to consolidate pt. orders and care needs in a centeralized concise way
-recording of pt. care in descriptive form
-includes the basic patient need or problem data, whether someone was contacted, care are treatments provided and the patients response to treatment
-written in an abbreviated story form
calssified system of technical/scientific names and terminology
nursing care plan
guidelines used to care for pt. with similar health problems, developed to meet nuring care needs of pt.
form on pt. chart, nurse records observation, care given, pt. response
-Institutions reimbursed by insurance companies or government programs only for the patient care documented
appraisal by professional co worker of equal status
Problem Oriented Medical Record (POMR)
Designed for physicians
Uses SOAPIER notes
-This is based on the scientific problem solving system or method
-Principal sections are database, problem list, care plan and progress notes
-Active, inactive, potential, and resolved problems served as the index for chart documentation
-A care plan with nursing diagnosis is developed for each problem by disciplines involved with the patient's care
quality, assurance, assessment, improvment
An audit in health care that evaluates services provided and the results achieved compared with accepted standards
Seven different aspects of charting: Form of POMR
-Subjective (how patient feels)
-Objective (actual data)
Traditional block chart
emphasis on specific section or sheet, emphasis is placed on specific sheets of info.
-For all Medical Records: Each page must contain Patient's name and Patient Medical Record
-Typical sections are admission sheet, physicians order, progress notes, history and physical examination data, nurses admission info, care plan, and nurses notes, graphics and lab and x-ray reports
focus on problem at hand, immediate problem (DARE)
-Form filled out with any event not consistent with routine operation of health care or pt. care
-Used when a patient care was not consistent with facility or national standards of expected care
-Give only objective, observed information
-DO NOT admit liability!
clinical critcal pathways
team of specific professionals that are all involved, like IEP
omnibus buget reconciliation act
2 common forms of charting
5 basic purposes for accurate and complete written patient records:
1. Written communication
2. Permanent record for accountability
3. legal record of care
5. Research and data collection
What does your signature mean?
-You are signing that YOU did all the work documented (that you performed)
-The MD orders (wound care done, medication given) were carried out. The patients needs were met. May include family visits, interventions by other departments, MD visits.
Common Medical Abbreviations and Terminology
-Most facilities have a published list of generally accepted medical abbreviations and terms approved for use in charting and those not to use
-Careful abbreviations: ex. B.S. could mean breath sounds, blood sugar or bowel sounds
Calculating I & O
Include only liquids, nothing with solids in it
Charting Data Clusters
-Helps care providers to identify patterns that will assist with the identification of nursing diagnosis
-Give the data cluster for Dehydration
-Give the data cluster for cold/flu
Focus Charting Format
-Instead of problem lists, a modified list of nursing diagnoses is used as an index for nursing documentation
-This format uses the nursing process and the more positive concept of the patient's needs rather than the medical diagnoses and problems.
Data, Action, Response (and evaluation) Education )patient teaching)
-Data- subjective and objective = assessment in nursing
-Action= planning and implementation
-Response= evaluation of effectiveness
-Education=may include when pt to notify nursing staff
Charting by Exception (CBE)
-Hospital policy to address care
-Includes: Physical assessments, observations, vital signs, IV(site, fluids, rate), & significant data (safety) at beginning of shift
-During shift noting additional txs done or not done, changes in pt condition & new concerns.
Problem Intervention and Education
-similar to SOAPE (Medical Model)
-PIE (nursing Process)
-Variation: APIE = Assessment
-A = Subjective and Objective
Alternative Record Keeping
-Many forms eliminate the need to duplicate repeat data in the nurses notes
-It is unnecessary to chart a narrative note each time a medication or a bath is given or vital signs are assessed.
Card system used to consolidate patient orders and care needs in a centralized, concise way. Kept at the nursing station for quick reference.
Nursing Care Plan
-Preprinted guidelines used to care for patients with similar health problems
-Developed to meet the nursing needs of a patient
-Based on nursing assessment and diagnosis
24 hour Patient care records acuity and charting forms
Consolidation of the nursing records into a system that accommodates a 24 hour period is often done
-This aids in the elimination of unnecessary record keeping forms
-Accurate assessment info and documentation of ADLs are more easily obtained in 24 hr. charting
Discharge Summary Forms
-Info is provided that pertains to the patients continued health after discharge
-Includes Medication Reconciliation Form, Referrals for therapy/home health, follow up with the PCPhysician
-Discharge summary forms make the summary concise and instructive
Clinical (critical) Pathways
-Managed care is a systematic approach that provides a framework to target the coordination of medical and nursing interventions
-Allows staff from all disciplines to develop integrated care plans for a project length of stay for a specific type.
-The nurse and other team members use the pathway to monitor a patient's progress and as a documentation tool.
Home Health Care Documentation
-Medicare fas specific guidelines for establishing eligibility for HHC reimbursement
-Documentation by HHC nurses has become the largest problem area 50% of the nursing time is spent in documentation.
-Documentation is both the quality control and the justification for reimbursement from medicare and Medicaid or private insurance companies
-HHC documentation has unique problems b/c of the needs for different health providers to access the medical record
Long-term Health Care Documentation
OBRA of 1987 regulated standards for resident assessment, individualized care plans, and qualifications for health care providers
Dept. of Health for each state governs the frequency of written nursing records of residents in a long-term care facility
-Long-term care documentation supports a multidisciplinary approach in the assessment and planning process of the patients.
Record Ownership and Access
-The original health care record or chart is the property of the institution or physician
-The patient usually doesn't have immediate access to their records
-Patients have gained access rights to their records in most states but only if they follow the established policy of the facility
-A lawyer can gain access to a chart with the patients written permission
-Health Care personnel must respect the confidentiality of the patients record
-The Patient's Bill of Rights and the law guarantee that the patient's medical info will be kept private, unless the info is needed in providing care or the patient gives permission for others to see it.
-The nurse should not read a record unless there is a clinical reason and should not hold the information regarding the patient confidence, The nurse must have a "need to know" what is in the medical record.
Use of computers
Many institutions have mainframe computers for data processing tasks
-Most billing is now stored and processed on this type of computer.
-Many progressive hospitals have installed computers that can handle physician orders, pharmacy, laboratory, diagnostic imaging orders, central supply requests, care planning, documentation and billing
-The most efficient computer systems have bedside or handheld terminals for data entry.
-The password used to enter and sign off computer should never be shared.
-Never leave he computer terminal unattended after being logged on.
-Follow correct protocol for correcting errors
-Make sure that stored records have backup files
-Don't leave info about a patient displayed on a monitor with others can see it.
-Follow agencies confidentiality procedures for documenting sensitive material
-Printouts of computerized records fould be protected and secured
-Quality and accuracy of nots is important
-Correct spelling, grammar, punctuation is important
-Info should be clear and concise
-RN has primary responsibility for the initial admission nursing history, physical assessment and development of the care plan based on the nursing diagnosis identified.
Use of Fax machines
-Fax machines are a vital channel for rapid info transmission and are as important as computers and documentation and data handling.
Basic rules for charting
-Correct patients name, date , time
-Use only approved abbreviations and medical terms
Be timely, specific accurate and complete
-Grammar and punctuation
-Fill all spaces, chart consecutively, line by line. -No indentation on left margin
-Chart after care is given not before.
-Chart as soon as ofter as possible
-Chart your own care, observations, and teaching, never chart for anyone else
-Use direct quotes when appropriate
-Describe each item as you see it
- Be objective (only what you see, feel and smell)
-chart facts, avoid judgement and placing blame
-sign each block of charting with full legal name and title
-When patient leaves unit, chart time, method of transportation on departure and return
-Chart all ordered care as given or explained deviation
-Note patient response to treatment and response to medication
-Use black pens no erasures or correcting fluids allowed on charts
-If charting error is made, draw one line through it and mare error
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