Term
| Essential among healthcare professionals to provide coordination and continuity of care |
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Definition
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Term
| What does effective communication help |
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Definition
| to support and complement one another s service and helps avoid duplications in care |
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Term
| What should you look at when you document |
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Definition
| Relationships and patterns |
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Term
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Definition
| nurse to nurse, nurse to physician, nurse to pt/ family, dept to dept |
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Term
| what should you record or document |
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Definition
| pt progress toward goals of treatment |
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Term
| you should document your__- |
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Definition
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Term
| is the written or typed legal record of all pertinent interactions with the patient-assessing, diagnosing, planning, implementing, and evaluating |
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Definition
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Term
| this is compiling of all of the health information. It facilitates pt care. Serves as legal and financial record. It helps in clinical research and to support data analysis |
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Definition
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Term
| What are the 8 guidelines for effective communication |
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Definition
1. complete
2. accurate
3. concise
4. factual
5. organized
6. timely
7. legally prudent
8. confidential |
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Term
| All information about patients is considered _______or _______. whether it is written, on paper, or saved on a computer or spoken aloud |
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Definition
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Term
| What are potential breaches in patient confidentiality |
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Definition
1. conversations that can be overheard
2. leaving chart open and in view of others
3. leaving info on computer screens
4. sharing passwords
5. Releasing into to unauthorized people
6. Trash-should be shredded or placed in bin
7. E-mail
8. Faxing to wrong person
9. cell phone conversations and pagers |
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Term
| what are the patients right |
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Definition
1. has right to see and copy medical records
2. to update record
3. to get a list of disclosure
4. to request a list of certain disclosure
5. has right to know how they will receive health information |
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Term
| Most agencies have their own___regarding records |
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Definition
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Term
| Most agencies will allow health care students access to charts, but ______ |
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Definition
| the students are held to the same standards of privacy |
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Term
| You should not use pt name on ________for school |
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Definition
| do not use pt name on written or oral reports for school |
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Term
| What are the purposes of patient records |
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Definition
1. communication
2. diagnostic adn therapeutic orders
3. care planning
4. quality review
5. Research
6. Decision analysis
7. education
8. legal documentation
9. reimbursement
10. Historical documentation |
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Term
| What purpose does communication serve in regards to pt records |
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Definition
| It helps to facilitate communication and continuity of care between many disciplines who may have little face to face contact |
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Term
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Definition
| by quality of documentation and how well you communicate |
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Term
| What is significant about the pt chart |
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Definition
| it is the best and maybe the only communication you have with other departments |
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Term
| In regards to diagnostic and therapeutic orders all tests or studies done since admission are ____________ |
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Definition
| documented in the chart, as well as the results as they become available |
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Term
| Who may an RN accept orders from |
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Definition
| Physicians, NP, avanced practice RN, psychologists, pediatrist, dentist, & maybe med student (resident) |
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Term
| When are verbal orders given |
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Definition
| Verbal orders are given only during a medical emergency when the physician /NP is present but cant write the order due to the nature of the emergency |
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Term
| What are the steps to take when taking a verbal order |
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Definition
1. read back
2. note date
3. note time
4. sign order
*have name & title of ordering professional followed by the nurse name & title ex. S. Ely RN MSN |
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Term
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Definition
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Term
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Definition
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Term
| What is significant about each facility regarding telephone and fax orders |
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Definition
| each facility will have its own policy regarding telepone/ fax orders |
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Term
| When taking a telephone or fax order what must the receiving RN do |
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Definition
| the receiving RN must read back the order to ensure accuracy. Read each number clearly (15mg is stated as "one five mg) |
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Term
| If you are a receiving RN of a telephone order and you are not sure of the order you heard what do you do |
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Definition
| Have the physician repeat the order to another RN |
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Term
| Most phone orders need to be signed within what period |
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Definition
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Term
| Why must each professional working with the patient have access to ongoing data |
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Definition
| Each professional working with the patient must have access to ongoing data to determine teh appropriateness of the care given |
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Term
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Definition
| Quality review is a system of review of charts to ensure that the care given meets a minimum of quality and competence standards set for each type of patient situation |
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Term
| Why are patient records studied |
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Definition
| Patient records may be studied to learn how to best recognize and treat health problems in similar cases |
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Term
| what does chart review help with |
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Definition
Chart review can help an institution to make several types of decisions.
ex. Trending
ex. over used or underused services |
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Term
| Records are ______that can be used in court proceedings |
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Definition
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Term
| How are patient records related to reimbursement |
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Definition
| Patient records are used to prove to insurance companies that the patient received th ecare that is being billed for |
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Term
| How can pt records be used for historical documentation |
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Definition
| Can be used to provide vital health information about a patients past health problems and care |
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Term
| What are some methods of documentation |
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Definition
1. Source- Oriented Records
2. Problem- Oriented medical Records
3. PIE- Problem, Intervention, Evaluation
4. Focus Charting
5. Case Management Model
6. Computerized Records
7. Personal Health records |
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Term
| what is significant about each discipline and documentation |
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Definition
| Each discipline has its own forms and its own place in the chart to record information |
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Term
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Definition
| Problem Oriented Medical Records |
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Term
| What is POMR organized around |
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Definition
| organized around the patients problems rather than the source of the info |
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Term
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Definition
Subjective
Objective
Assessment
Planned |
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Term
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Definition
Subjective
Objective
Assessment
Planned
Interventions
Evaluation
Response |
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Term
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Definition
Problem
Intervention
Evaluation |
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Term
| When you are doing PIE what needs to be done at the beginning of each shift |
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Definition
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Term
| What is an advantage and disadvantage of using PIE |
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Definition
| no need for separate care plan but problem is usually that the patient has multiple problems and you would need to read all nurse notes because no cardex |
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Term
| What is the purpose of focus charting |
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Definition
purpose is to bring focus of care back to patient and his/ her concerns instead of care plan
uses DAR |
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Term
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Definition
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Term
| This is shorthand documentation where only "exceptions" to expected standards are documented |
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Definition
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Term
| What are some advantages and disadvantages to charting by exception |
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Definition
takes much less time to chart, which frees up time for direct care
Sometimes hard to prove quality or if you have a negligence type lawsuit |
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Term
| With emphasis on quality what do you see more of |
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Definition
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Term
| What will you not see in a long term care facility |
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Definition
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Term
| Emphasis is on cost-effective, quality care delivered within a limited amount of time |
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Definition
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Term
| What is a limitation to case management |
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Definition
| typical patient outcome may not be the actual patient outcome |
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Term
| this is a flow sheet for a given patient situation |
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Definition
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Term
| Used when a patient has an unexpected event. Variences most often documented affect quality, cost, and length of stay |
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Definition
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Term
| Very common method of record keeping now |
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Definition
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Term
| What are some advantages and disadvantages to personal health records |
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Definition
They provide acurate and complete health information that will assist in the care and communication with providers
alot of physicians are slow to accept computerized versions |
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Term
| What are some formats for nursing documentation |
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Definition
1. initial nursing assessment
2. Kardex and patient care planning
3. Plan of nursing care
4. Critical/ collaborative pathways
5. Progress notes
6. Flow sheets
7. Discharge and Transfer summary
8. Home healthcare documentation
9. Long term care documentation |
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Term
| The results of 1 in 4 malpractice suits are determined based on the documentation in the________ |
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Definition
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Term
| What may be your only defense in a lawsuit that occurs years after you have cared for a patient that you can no longer even remember |
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Definition
| your documentation in the patients chart |
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Term
| This is your baseline for info |
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Definition
| Initial nursing assessment |
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Term
| this is a quick easy way to convey a plan of care. it is not a part of the medical record. Just there for the nurse on a daily basis |
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Definition
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Term
| Purpose is to inform care givers of progress |
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Definition
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Term
| Summary of Condition and Treatment instructions |
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Definition
| Discharge and Transfer summary |
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Term
| helps the staff to gather specific info on residents strength and weakness |
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Definition
| Long term care documentation |
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Term
| What are some ways to report care |
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Definition
1. change of shift
2. telephone/ telemedicine reports
3. Transfer of discharge reports
4. reports to family members/ significant others
5. Incident reports |
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Term
| Hand off report from one nurse to another. it can be oral, written, or taped. includes; name, rm#, bed#, diagnosis, current appraisal of health status |
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Definition
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Term
| Type of report where you call the physician with any info that needs conveyed. Have chart in hand and near computer |
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Definition
| Telephone/ Telemedicine Reports |
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Term
| Type of report where you need ok from patient before you disclose any info to anyone |
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Definition
| reports to family members / significant others |
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Term
| report used when you have harm or potential for harm |
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Definition
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Term
| What are 3 ways to confer about care |
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Definition
1. Consultations and referrals
2. Nursing and Interdisciplinary Team Conferences
3. Nursing Care Rounds |
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Term
| to confir with someone seek ideas, seek information, advise, or instruction |
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Definition
| Consultations and Referrals |
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Term
| If pt needs longer length of stay we can have pt care consult between nurses |
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Definition
| Nursing and Interdisciplinary Team Care Conference |
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Term
| nurses can make rounds with and share information |
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Definition
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Term
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Definition
Situation
Background
Assessment
Recommendation |
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Term
| In SBAR what is included in situation |
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Definition
Nurse name
unit
Pt name
Rm #
tell about problem |
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Term
| In SBAR what is included in background |
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Definition
| admission diagnosis, date of admission, pertinent med Hx, brief synapses of treatment to date |
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Term
| In SBAR what is included in assessment |
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Definition
most recent vitals
if pt is or is not on oxygen
any changes from prior assessments such as mental status, skin color, neuro changes, musculoskeletal |
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Term
| What is included in recommendations for SBAR |
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Definition
| Do you think we should. Can you come see the pt, what would you have me do |
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Term
| National patient safety goals |
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Definition
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Term
| What do you need to have ready b4 calling the physician |
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Definition
1. assess the patient
2. review the chart for the appropriate physician to call
3. know the admitting diagnosis
4. Read the most recent progress notes and the assessment from the nurse of the prior shift
5. have available when speaking with the physician; chart, allergies, meds, iv fluids, labs/ lab results |
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