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p&p cp 8
documentation
Question | Answer |
---|---|
Effective documentation | ensures continuity of care, saves time, minimizes the risk of errors. |
Documentation needs to conform to the standards of the -------- to maintain institutional accreditation and minimize liability. | JCAHO Joint Commision for Accreditation of Healthcare. |
Documentation | Anything written or printed in PT record. Reflects the quality of care, and provides accountability for each health care giver. |
Record | legal, written, communication, regarding the client's health care status. |
Report | oral, written or audiotaped exchange of info. |
Common Reports | Change of shift report, telephone reports, transefer report, incident report. |
Purpose of records | Documentation serves multiple purposes: it facilitates communication with health care providers for continuity of care, it aids in clinical research, and it guides professional and organizational perormance improvement. |
6 purposes of records | communication, legal documentation,financial billing, education, research, auditing & monitoring. |
DRG | Diagnosis related groups- are the basis for establishing reimbursement for PT care. |
A DRG is a | Classification based on PT's primary and secondary medical diagnosis. Under the prospective payment system (PPS), Medicare reimburses hospitals a set dollar amount for each DRG. |
Documentation verifies | the specific nursing care provided and thus supports the reimbursement your health care agency receives. Timely and accurate documentation of supplies and equipment used assists in determining the PT financial charges. |
Education with the PT record | The PT's record contains a variety of info, medical/nursing dx, signs/symptoms of disease,findings,ect..., reading the record is and effective learning tool for student nurses/drs. |
Research | statistical data |
Auditing and Monitoring | JCAHO requires hospitals to establish performance improvement programs to conduct obj.ongoing reviews of PT care - asks institution to establish stadards for quality care. |
Performance improvment programs | Keep you informed of the extent to which you meet standards of nursing practice. |
Accurate Recording | best defense against legal claims |
6 charactoristics of Quality Reporting | factual, accurate, complete, current, organized, confidential |