Term
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Definition
| Written or typed legal record of pertinent interactions with the patient. ADPIE |
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Term
| What is the primary reason for documentation patients records? |
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Definition
Communication
But others are:: Continuity, legal proof, safety, and for billing reimbursement. Record of orders, care planning, quality review, research, decision analysis, education, legal documentation, historical documentation. |
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Term
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Definition
The Joint Commission(TJC), is a agency accreditation of healthcare organization.
Requires the nursing process(adpie) to be part of pt. permanent record. |
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Term
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Definition
Health insurance portability & accountability act (1996)
-Assures that patients records are keep confidential & privacy.
-2002 updated now people who violate them there are fines & jail time.
-pt have right to...see, copy, update list of disclosures (TX, pmt, operations) request a restriction on uses & disclosures how to receive info. |
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Term
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Definition
| American Nurses Association. Developed a code of ethics for nurses with interpretive statements standards of clinical nursing practicing and standard terminology. |
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Term
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Definition
| National committee for Quality Assurance~ |
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Term
~Consistent with standards
~Complete
~Accurate
~Concise/short
~Factual
~Organized and timely
~Legally prudent
~Confidential |
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Definition
Effective Documentation
A good record being a good defense. Chart observation, not just interpretation. Use pt. words, military time, chart after care, not before. Avoid words like normal, seems like, be very specific, not general. No spaces, erasers, white-out, signed, logical, good spelling, use abbrev that are approved. |
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Term
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Definition
| JACO uses random CHARTS to review quality of the care plans in order to find areas for improvement. |
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Term
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Definition
| Data collected, exp; off all of the patients admitted with an open wound, how many developed a staff infection after being admitted into the hospital? |
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Term
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Definition
-keeps data on its own separate form.
-separate narratives by area providing care.
-Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel, and so on.
-Advantage is that each department can easily find and chart pertinent data.
-Disadvantage is that data are fragmented, making it difficult to track problems chronologically with input from different groups of professionals. |
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Term
| POMR (Problem Oriented Medical Record) |
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Definition
Originated by Dr. Lawrence Weed in 1960s.
-Organized around patients problems rather than around sources of information.
All healthcare professionals record information on the SAME FORM.
-Advantage is that it's collaborative, same form, PROGRESS NOTES clearly focused.
-Disadvantage is that it is narrow focus and narrative form. |
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Term
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Definition
Subjective data
Objective data
Assessment (The caregivers judgement...about the situation)
Planning
This is an example of a problem oriented medical record (POMR)organize data entries in the progress notes. |
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Term
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Definition
Intervention
Evaluation
Response |
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Term
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Definition
Problem=nursing diagnoses
Intervention=what did nurse do?
Evaluation=how did pt. respond?
-Disadvantage no formal care plan
*Plan of care incorporated into notes
-Advantage promotes continuity, saves time, use same system.
an advantage is promotes continuity of care, saves time because there is no separate care plan. The disadvantage of not having a formal care plan is that nurses need to read all the nursing notes to determine problems and planned interventions before initiating care. |
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Term
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Definition
Data
Action
Response
Written in a narrative.
-focus of care on patient & patients concerns.
-Pt. strengths, problems or needs.
-Can be one at a time or a combo of DAR.
-Advantage is the holistic emphasis on the patient and the patient's priorities.
-Disadvantage is artificial categories. Choices may not be specific enough. Not a systematic nursing process not using a label. |
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Term
Charting by exception (CBE)
(variance charting) |
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Definition
a shorthand documentation method
-only significant findings or "exceptions" to these standards are documented in narrative notes.
-Advantage;decreased charting time,
-eliminates repetition
-subjective data
-easy to track unexpected changes
a greater emphasis on significant data, easy retrieval of significant data, timely bedside charting, standard assessment, greater interdisciplinary communication, better tracking of important patient responses.
-Disadvantage; Poor defense regarding a negligence claim. |
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Term
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Definition
-Promotes collaboration, communication, and teamwork among caregivers, makes efficient use of time and increases quality by focusing care on carefully developed outcomes.
-Works well for typical patients with few needs. |
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Term
| Computerized Documentatation(record)/ EMR=Electronic medical records |
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Definition
What most of the hospitals & ECF use.
Electronic medical records.
Benifits:
-Errors,
-Productivity(less time charting), -Standardized format
Considerations:
-Passwords;security, log off system
-Correcting errors;
-Back up files
-Confidentiality; privacy, wonder where info is going if not sent to correct place. |
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Term
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Definition
| A careplan to communicate conveniently and concisely the plan of nursing care for each patient. Recorded on a folded card and placed in a central kardex file where it is easily accessible. The plan is eventually placed in the patients health record. The outside of the card (activity and treatment section) contains basic info; profile, admitting diagnosis, and orders concerning patient's activity level, diet, vitals, diagnostic test, medications, and other treatments and proceedures. The inside of the card, contains nursing careplan, specifying nursing diagnoses and health problems related to outcomes and nursing interventions and safety precautions. |
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Term
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Definition
| should be written concisely summarizes the reason for treatment, significant findings, the procedures performed, and treatment rendered, the patients condition on discharge or transfer, and any specific pertinent instructions given to the patient and family. |
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Term
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Definition
The Outcome and Assessment Information Set:
- Represent core items of a comprehensive assessment for an adult home care patient.
- Form the basis for measuring patient outcomes for purposes of outcome based quality improvement.
-a key component for Medicare's partnership with the home care industry to foster and monitor improvement with home healthcare outcomes. |
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Term
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Definition
-nurse to the nurse
-charge nurse to charge nurse who is replacing them.
-a written or oral meeting
Includes;
-basic identify info,
-health status with changes or improvements, pt response to therapy or meds,
-labs and monitoring,
-abnormal, where pt stands on reaching goals.
-current orders, changed orders, -upcoming or ongoing procedures/tests. |
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Term
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Definition
| document the occurrence of anything out of the ordinary that results in or has the potential to result in harm to a patient, employee, or visitors. |
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Term
I SBAR R
Introduction, Situation, Background, Assessment, Recommendation, Read back) |
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Definition
included by the joint commission.
-Introduce self: Name, what hospital, pt. name.
-Situation: communicate what is occurring and why the patient is being handed off to another department or unit.
-Background; Explain what let up to the current situation and put in context if neessary.
-Assessment: give yoru impression of the problem.
-Recommendation: Explain what you would do to correct the problem.
-Read back |
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Term
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Definition
Confer; is to consult with someone to exchange ideas or to seek information, advice, or instructions.
-Consultations-invite another professional to evaluate pt. & make recommendations.
-Referrals; Sending or guiding pt. to another source for assistance.
-Team care conferences; a nursing meeting to discuss some aspect of pt. care. Let everyone give opinion of problem, cause, and solutions.
-Nursing care rounds; 1st & 2nd shift nurses go room to room to share info on pts. Short summary, diagnoses & goals & care given. Advantage, actually see pt, & pt. can participate in their care.
Dr. rounds; see pt together, pool info & see what assessment finding are. |
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Term
| Correct documentation guidelines |
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Definition
-Enter information ina complete, accurate, concise, factual, and organized manner.
-Date and time each entry
-Document nursing intervention as closely as possible to the time of their execution.
-Note problems as they occur in a orderly,sequential manner. |
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Term
| According to the Health Insurance Portability and Accountability Act of 1996, patients have the right to...... |
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Definition
See and copy their health record,
-update their health record
-get a list of disclosures and healthcare institution has made independent of disclosures make for the purposes of treatment, payment, and health care operations.
-request a restriction on certain uses or disclosures
-choose how to receive health information |
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Term
| According to the Health Insurance Portability and accountability Act of 1996, if a health institution wants to release a patient's health informaiton purposes other than treatment, payment, and routine healthcare operation, the patient must be asked to sign an authorization. What are the exceptions to which an authorization is needed? |
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Definition
| The patient is a public figure and the local news media are preparing a report. Under no circumstance can a nurse provide information to a news reporter without the patient's express authorization. |
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Term
| If you were looking for trends in a patient's vital signs, what form should you consult first? |
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Definition
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Term
| This method of documentation uses the categories data, action, and response (DAR) to facilitate charting... |
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Definition
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Term
| A resident called to see a patient in the middle of the night is leaving the unit and remembers that he forgot to write a new order for a poin medication you had requested for another patient. Tired and already being paged to another unit, he verbally tells you the order and asks you to document it on the physician's order sheet. |
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Definition
| I'm sorry but verbal orders can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly. |
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Term
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Definition
-COMMUNICATION between all people taking care of pt. Place for us to have a RECORD of orders from PCP. Place to include CARE PLANS. A place for hospital to go look for info to approve/disapprove if QUALITY care is given. Use record to collect & REVIEW data & treat problems. Make decisions on what is in charts. EDUCATION we read charts to learn about health issues. If not LEGAL DOCUMENTATED care not given prove/disprove. Look at HISTORICAL documentation for PROOF OF CARE & REIMBURSEMENT.
-approve research |
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Term
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Definition
Go to provide standards & polices
-WHO HAS ACCESS TO RECORD
-abbrev approved. "Do not use"
-how are records stored.
Ex; breaches-computer, copier, phones, fax, voice. |
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Term
Critical Pathway/Care Maps
Also called Collaborative |
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Definition
"standardize POC" linked to expected outcomes along a timeline.
-Uses CHARTING BY EXCEPTION
a computerized system, flow sheets match each days expected outcomes. |
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Term
Variance charting
(CBE chart by exception) |
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Definition
can be positive or negative
chart unexpected event, the cause, adverse actions taken in response to the event & discharge planning.
quality, cost or length of stay |
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Term
Long term care documentations
Resident Assessment Instrument (RAI)
What are the four components? |
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Definition
System used in LT Care facilities
Pt. strengths, needs & POC
1. minumum data set- problems & conditions of pt.
2. triggers-at risk for problems, need further evaluation.
3. Residnet assessment protocol-social, med, nurising, psychological problems & POC
4. Ulilization guidelines- must use for facilities LTC |
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Term
| Personal health record (PHR) |
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Definition
Manage H/C via computer
-med HX
-diagnoses
-symptoms
-medications
May scan in dr.notes, tests results, CT, insurance info.
-Advantages; easy access to up-to-date info. Assist in care, & communicate with PCP. |
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Term
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Definition
-Interpretation of pt. pathology
-Response of pt. to medical therapy |
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Term
| (Nursing) Narrative notes |
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Definition
-Description of pertinent observation of pt.
-Nursing care, teaching, received & response.
-Pt. condition, progress, or lack of toward recovery & goal achievement.
-Pt. complaints & how they are coping or failing to cope with them & nursing response. |
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Term
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Definition
(ANA) integrates nursing, computer, information science to manage & communicate data, info & knowledge in nursing practice.
-Supports pts, nurses, other providers.
-^ accuracy & completeness of documentation.
-^ workflow & repetitiveness
-Automation of the collection & reuse of data.
-Analysis of clinical data |
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Term
Reporting
What are the 5 types of reporting? |
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Definition
1. Change in shift, summary
2. Telephone orders, lab results
3. Transfer reports, continued of care
4. Report to family, be very careful who you give info to.
5. Incident report, document, out of ordinary harm to pt, employee, or visitor. |
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Term
| What are the 10 common forms? |
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Definition
1. Flow sheets; used a lot, routine nursing care.
2. Graphic record/sheets; record V/S, P, RR, BP, T, W, I/O
3. I/O; 24 hr fluid intake/output
4. MAR; medication admin record
5. Acuity record; 24 hr document routine of care, goals, safety, well-being. Increased/decreased acuity to condition of pt. Also used for staffing based on acuity of pt.
6. Admission nursing HX; assessment
7. Care plan; based on nursing ADPIE
8. Pathways; standardize POC
9. Progress notes; narrative format, SOAP, PIE, FOCUS, EXCEPTION, CASE MNG MODEL
10. Discharge summary/transfer; Written summary, reason TX, finding, procedures performed, TX received, Pt. condition on discharge/transfer and any instructions given to pt/family. |
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Term
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Definition
-24 hr period document routine care & goals, safety & well-being.
-increased or decreased acuity to condition of pt.
-Also used for staffing based on acuity of pt. |
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