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CMIE chs 5-7
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something you should know | something else you should know |
---|---|
what is NMDS | nursing minimum data set |
what makes up the NMDS | nursing care (nursing diagnoses and interventions), pt demographics, service elements (i.e. length of hospitalization) |
whole point of documentation | a tool for communication among health team members----to provide the highest quality care for a patient |
how to chart | completely, concisely, and accurately |
avoid what | opinions |
when to chart | as soon as possible, never ahead of time, always in chronological order, with exact times |
how to write | legibly, black or blue ink, print, if not enough room, refer to other section where you can write fully |
what to use in charts | accepted abbreviations only |
how to correct for time | write late entry on first line available, include time it should have been written, and when it actually was |
how to correct a mistake | don't; draw one line through entire entry, write mistaken entry, and include date, time, and your signature or initials |
how to sign documents | use your name and licensure, sometimes job title, don't leave blank lines, draw a line through to your signature, like a check |
types of doctor's orders | written, telephone, verbal, preprinted |
what if you refuse to carry out an order | document refusal, reasons why, communications with the doctor. Inform your immediate supervisor. |
what controls what is charted | nurse practice acts, ANA, malpractice litigations, facility policies and procedures |
malpractice verdict needs what three things | breach of duty, damage, and causation |
stick to the | facts |
legally: avoid | labeling ----be objective |
be specific | avoid catch-all phrases and write what is measurable, or use direct quotations from pt |
use neutral | language; don't be inappropriate or unprofessional |
eliminate bias | document behavior objectively, let the jury draw their own conclusions |
keep the record | intact |
not charted | not done |
chart significant | situations in addition to flow sheets, etc |
chart complete assessment | data, never leave it out or for granted |
document discharge | instructions specifically, include teaching and evaluation of learning |
don't record staffing | shortages or problems, can be used against facility |
don't record staff conflicts | disputes c other nurses, questions about dr.s treatment, colleagues' abusive behavior |
don't EVER chart or mention | incident reports |
don't use words associated with | errors, like somehow, accidentally, unintentionally, confusing, miscalculated, etc... chart s calling undue attention instead |
don't name a second patient | use initials or room and bed numbers |
don't chart casual | conversations---tell a colleague why you are telling the info and what you want him to do, or can't chart it at all |
what is negligence | the failure to exercise the degree of care that a person of ordinary prudence would exercise under the same circumstances |
three requirements of negligence | duty owed by one person to another, breach of duty, resulting injury |
malpractice is a violation of | professional duty to act c reasonable care and in good faith |
risk management | focuses on pts' and family members' perception of care provided |
performance improvement | focuses on role of health care provider |
3 goals of risk management | decrease # of claims, reducing frequency of preventable injuries and accidents leading to litigation by maintaining or improving quality of care, controlling costs by pinpointing trouble spots early and working c pt and family to reduce |
most commonly used early warning systems | occurence reporting and occurrence screening |
occurrence screening | reviewing MR to find adverse evernts, consider both general and specific indicators |
2 functions of an incident report | informs admin of incident for risk managment, alerts admin and facility's insurance company to a potential claim and the need for further investigation |
legal hazard 1: incident | reports |
legal hazard 2: informed | consent |
legal hazard 3: advanced | directives: DNR, living will, Durable Power of Attorney |
legal hazard 4: patients who | refuse treatment- document refusal |
legal hazard 5: documenting by | unlicensed personnel |
legal hazard 6: using | restraints; document must include time-limited order, date and time and type of restraint used, behaviors that necessitate restraints, behaviors needed to removed restraints, daily evaluation by dr. |
legal hazard 7: pts who request | to see their charts; check facility's policy |
legal hazard: pts who leave | AMA |