Term
| Purposes of Patient Records |
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Definition
Communication with other healthcare professionals
Record of diagnostic and therapeutic orders
Care planning
Quality of care reviewing
Research
Decision analysis
Education
Legal documentation
Reimbursement |
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Term
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Definition
The act of recording client assessments and care in written or electronic form
Creating a record of client assessments and care |
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Term
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Definition
All information about patients written on paper, spoken aloud, saved on computer
Name, address, phone, fax, social security
Reason the person is sick
Treatments patient receives
Information about past health conditions |
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Term
| Breaches of confidentiality |
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Definition
Discussion in a public area
Leaving information in a public area
Unattended computer
Failure to log off
Sharing passwords
Improper access, review, or release of patient information
Discussion of patient information with those who have no need to know |
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Term
| HIPPA (Health Insurance Portability and Accountability Act )Patient Rights |
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Definition
See and copy their health record
Update their health record
Get a list of disclosures
Request a restriction on certain uses or disclosures
Choose how to receive health information |
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Term
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Definition
, etc-Subjective, Objective, Assessment, Plan or SOAPIER (Intervention, Evaluation, Response)
Select numbered problems from master list, then write SOAP note on progress sheet |
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Term
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Definition
Problem, Intervention, Evaluation, No separate plan of care. Complete assessment qs, flow sheet, document PIE in progress notes from numbered problems
Used only in problem-oriented charting
Establishes an ongoing plan of care |
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Term
| Source-Oriented Patient Records |
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Definition
Disciplines charted separately: each person/dept. has own section
Variety of sections (e.g., admission, H&P, diagnostic, graphic, nurses’ notes, progress notes, lab, rehab, DC plan, etc.)
Data scattered; may lead to fragmentation |
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Term
| Problem-Oriented Clinical Records |
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Definition
Data about the patient is arranged according to patient health problems
Four components: database, problem list, plan of care, and progress notes
Each person/department makes notations that are integrated throughout the patient’s chart
Allows greater collaboration |
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Term
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Definition
Highlights the client’s concerns, problems, or strengths in three columns
Column 1: Time and date
Column 2: Focus (strength, need) or problem being addressed
Column 3: Charting in a DAR format: Data, Action, Response |
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Term
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Definition
Uses well defined standards of practice
Chart only significant findings or exceptions to norms
Streamlines charting and saves time
Uses preprinted forms and checklists
Inadvertent omissions are biggest problemCharting by Exception
Documentation system in which only significant findings or exception to norms are recorded
Critical Pathway
Computer Documentation |
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Term
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Definition
Collaborative pathways – Critical pathways – care map
Variance charting – unexpected event, cause, action, response, d/c plan |
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Term
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Definition
Electronic Health Record
May combine source oriented and problem oriented recording styles |
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Term
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Definition
Can use with source- or problem-oriented system
“Story” of care in chronological format
Tracks the client’s changing status
Can be lengthy and disorganized |
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Term
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Definition
Flow sheets individualize specific services
Assessment with baseline data
Concise progress notes
Timely entries |
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Term
| Standardized Nursing Care Plans |
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Definition
Identify common problems
Related care for select population group
Still need to be individualized
Formats vary |
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Term
| Nursing Documentation Forms: Nursing Admission Assessment |
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Definition
Record of baseline data from which to monitor change
Helps forecast future needs
Admission Data Base
Chief complaint or reason for admission
Physical assessment data
Vital signs
Allergy information
Current medications
ADL status and discharge planning information/ needs
Data about client support system and contact information |
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Term
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Definition
Record routine aspects of care (hygiene, turning)
Document assessments; usually organized according to body systems
Track client response to care (wound care, pain, intravenous fluids) |
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Term
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Definition
- used to record vital signs
Intake and output record |
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Term
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Definition
Medication Admin. Record
Comprehensive list of all ordered medications
Provides information on client’s medication allergies
Documents scheduled/routine, PRN, STAT, or omitted doses
Additional explanation may be required for nonroutine or omitted medications |
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Term
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Definition
Demographic data
Medical diagnoses
Allergies
Diet/activity orders
Safety precautions
Intravenous therapy orders
A summary of medications ordered
Ordered treatments (wound care, physical therapy), surgery, laboratory, and tests
Special instructions such as preferred intensity of care or isolation orders |
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Term
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Definition
A combined charting and care plan form
Maps out on a daily basis, from admission to discharge
Client outcomes, interventions, and treatments for a specific diagnosis or condition
Laboratory work, diagnostic testing, medications, and therapies included in the pathway |
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Term
| How to Deal With a Recording Error |
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Definition
Draw a single line through the error
Do not erase or blot out the error
Initial the corrected recording error |
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Term
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Definition
Draw a line through the blank space so no additional information can be recorded at any other time or by any other person
Sign the notation |
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Term
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Definition
Basic identifying information about patient
Current appraisal of patient’s health status
Changes in medical conditions and patient response to therapy
Where patient stands in relation to identified diagnoses and goals
Current orders (nurse & physician)
Summary of each newly admitted patient |
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Term
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Definition
May be:
Verbal
Through walking rounds
Audio-recorded report (not the preferred method)
Hand Off Report continued:
Client demographics and diagnoses
Relevant medical history
Significant assessment findings
Treatments (e.g., wound care, breathing treatments)
Upcoming diagnostics or procedures
Restrictions (e.g., diet, activity, isolation)
Plan of care for the client
Concerns
Use a standardized format such as SBAR or PACE
SBAR: Situation-Background-Assessment-Recommendation
PACE: Patient/Problem, Assessment/Actions, Continuing/Changes, Evaluation
Keep it CUBAN
Confidential
Uninterrupted
Brief
Accurate
Named Nurse |
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Term
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Definition
Your contact information
Client demographics, diagnoses, reason for transfer
Family contact information
Summary of care
Current status, including medications, treatments, and tubes in the client
Presence of wounds or open areas of the skin
Special directives, code status, preferred intensity of care, or isolation required
Always ask if the receiver has any questions |
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Term
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Definition
Time of departure and method of transportation
Name and relationship of person(s) accompanying client at discharge
Condition of client at discharge
Teaching conducted and handouts/informational matter provided to client
Discharge instructions (including medications, treatments, or activity)
Follow-up appointments or referrals given
Components of Discharge Summaries
Description of patient’s condition at discharge
Current medications
Treatments
Diet
Activity level
Restrictions |
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Term
| Discharging a Patient Against Medical Advice (AMA) |
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Definition
Procedure to follow when discharging a patient AMA:
ascertain why the patient wants to leave AMA
notify the physician
offer the patient the appropriate form to complete
if the patient refuses to sign the form, document this fact on the form and have another health professional witness this
provide the patient with a copy of the signed form and place the original in the record
when the patient leaves the agency, notify the physician, nurse in charge, and agency administration as appropriate
assist the patient to leave as if this were a usual discharge from the agency (the agency is still responsible while the patient is on the premises) |
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Term
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Definition
Date and time the orders issued in an emergency
Record orders in patient’s medical record
Read back the order to verify accuracy
Record “V.O.”, the name of the physician, and the nurse’s name
Physician responsibility to check & sign |
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Term
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Definition
Write the order only if you heard it yourself
Make sure the verbal orders make sense with the client’s status
Repeat the order to confirm accuracy
Spell unfamiliar names; pronounce digits of numbers separately
Directly transcribe the order on the chart
T.O.
Date/time
Text
To followed by provider’s name
Your signature
Physicians must countersign within 24 hours |
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Term
| Home health care documenting: |
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Definition
Home-bound status
Assessment highlighting changes in the client’s condition
Interventions performed (wound care, teaching, etc.)
Client’s response to interventions
Any interaction or teaching that you conducted with caregivers
Any interaction with the client’s physician |
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Term
| Long Term Care Documenting: |
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Definition
Minimum data set (MDS) for resident assessment and care screening must be completed within 4 days of admission and updated every 3 months
Long Term Care Weekly Summary:
A summary of the client’s condition
An evaluation of the client’s ability to perform ADLs
The client’s level of orientation and mood
Hydration and nutrition status
Response to medications
Any treatments provided
Safety measures used (e.g., bed rails) |
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Term
| If a client refuses medication: |
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Definition
Record on the medication administration record in narrative form; chart the reason given
Do not leave blank lines
If you make a mistake, draw a single line through the entry and place your initials next to the change
Sign all your charting entries |
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Term
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Definition
| Sending or directing a patient to another person, or agency, for help or treatment |
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Term
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Definition
A procedure in which a group of nurses visits all or selected patients at each patient's bedside to do the following:
obtain information that will help plan nursing care
provide the patient with the opportunity to discuss their care
evaluate the nursing care the patient has received |
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Term
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Definition
belief about the worth of something
what matters
that acts as a standard to guide one’s behavior |
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Term
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Definition
organization of values in which each is ranked along a continuum of importance
often leads to a personal code of conduct |
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Term
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Definition
observe parents or peers
socially acceptable/unacceptable behavior |
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Term
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Definition
taught value system
allows little chance for weighing different values |
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Term
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Definition
explore and develop on own
little guidance-confusion and conflict |
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Term
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Definition
rewarded for demonstrating appropriate values
punished for unacceptable values |
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Term
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Definition
encourage to explore and weigh consequences
support offered as weigh competing values |
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Term
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Definition
Concern for welfare/well-being of others
Aware of others beliefs, culture, perspective
Advocate – stand up for
Mentor colleagues |
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Term
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Definition
Right to self determination
Patient rights – decide own care
Provide info. for patients to make informed decisions
Partner with patient to plan care |
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Term
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Definition
Respect worth, uniqueness of people
Confidentiality, privacy, culturally competent/sensitive care |
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Term
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Definition
Act based on code of ethics and accepted standards of practice
Honesty, correct errors, accountability
Document accurately |
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Term
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Definition
Uphold legal, humanistic, & moral principles
Fair and equal treatment
Universal access to healthcare
Legislation
Policy making |
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Term
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Definition
Process:
Understand own values and value system
Important for nursing
Understand what motivates your patients
Use for teaching and counseling
Reflect on own values
Understand self
Practice non judgmental (value neutrality) |
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Term
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Definition
Choosing freely
Choosing from alternatives
Choosing after consideration of the consequences
Prizing with pride and happiness
Prizing with public affirmation
Acting with incorporation of the choice into one’s behavior
Acting with consistency and regularity on the value |
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Term
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Definition
Private, personal, or group standards of right and wrong
Moral behavior; in accordance with custom; reflects personal moral beliefs |
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Term
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Definition
Systematic study of right and wrong conduct
Formal process for making consistent moral decisions
Ethics
Systematic inquiry
Principles of right and wrong
Good vs. Evil
Make decisions
Ethically justified manner
Nursing code of ethics
Code of professional conduct
Refer to Box 44-3 (Wilkinson, text) |
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Term
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Definition
Responsible research conduct
Genetic enhancement
Environmental |
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Term
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Definition
“Bedside” ethical problems
Consent= valid
Refusal of consent
Assisted suicide requests |
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Term
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Definition
| (consequentialist theory) — the rightness or wrongness of an action depends on the consequences of the action |
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Term
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Definition
— an action is right or wrong independent of its consequences
Popular approaches used by nurse ethicists |
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Term
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Definition
Nurse-Patient Relationship
Caring relationship
Promote dignity & respect
Pay attention to particulars of each patient
Responsibility: others & profession
Moral skills: kindness, attentive, empathy, reliable, compassion |
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