Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Documentation
Documentation for NU112
| Question | Answer |
|---|---|
| Documentation | - Written or typed record of all pertinent patient interactions facilitating patient care. |
| Patient Record | - Compilation of a patient's health information, nursing information, nursing responsibilities policy, follows professional standards and local polices. |
| JCAHO Specifications | - Assessment diagnosis/patient needs, interventions and outcomes. - Permanent legal record and is best def. - Omissions, Repetition, inaccuracies, cause legal problems. |
| Content | - Complete, accurate, professional, specific, precautions/prevention, responsive, legally prudent, avoid inappropriate terms. |
| Timing | - Prompt - date/time, military time - never predocument |
| Format | - right chart/patient information - follow policy - legible/grammar/spelling - use acceptable terminology, abbreviations - - never skip lines, draw a line through blank spaces |
| Accountability | - First initial/last name/title - no dittos/erasures/correction fluid - use "mistaken entry" or error in charting" - identify each page with pt. Name/ID # - Permanent/complete |
| Confidentiality | - Follow Policy/legislation - professionally and ethically bound |
| What is Confidential | - All Patient information written, spoken, and computerized - Name - Address - Phone/fax - S.S. Number - Illnesses/Treatments - Information about past health conditions |
| Potential Violations | - Info displayed on screen - public email, facebook, etc. - shared printers - use marker on trash - inappropriate conversation - faxing - overhead paging - failure to log off - improper access, review or release |
| HIPAA | - Health Insurance Portability and Accountability Act - See and copy health record - Update Health Record - List of Disclosures - Restrict uses or disclosures - Choose how to receive health information |
| When is Authorization Not needed | - Treatment - Payment - Routine healthcare operations |
| Permitted Disclosure | - Public Health-Disease outbreaks - Infection control - Stats of dangerous drugs/devices - Law enforcement - disaster victims - Child abuse, neglect, domestic supoena - Low organ donation, death in a crime |
| Incidental Disclosures | - Sign in Sheets - Confidential interviewing - Patient carts outside rooms - White Boards - X-ray light boards - appointment message reminders |
| Verbal Orders | - Medical Emergency - Received by RN or pharmacist who documents and executes order, date & time - Reads back to verify accuracy - Record VO, name of practitioner nurses name and initials and title |
| More on Verbal Orders | - responsible to review for correctness sign name/title/pager number, date & time within a specific time, - restraints, narcotics, anticoagulants, and antibiotics within 24 hours - Questionable orders have another RN listen |
| Documentation Methods | - Source-orientated - Problem-orientated - PIE - Charting by exception - Case management - Computerized - electronic Med. Records |
| Source-Orientated Documentation | - Is filed by group(physicians, nurses ,lab) - each one can easily find but fragmented |
| Problem-Orientated Documentation | - POMR - Problem orientated medical record - organized around patient problem - all HCPs use the same form - SOAP notes (subjective, objective, assessment, plan) |
| PIE Documentation | - Problem, Intervention, Evaluation - incorp. paln of care into progress notes - problems are id by number - complete assessment done each shift |
| Foucs Documentation | - holistic care is focused on patient using narrative DAR (Data, action, response) |
| Charting by Exception | - Short hand documentation of sig. Findings. - lower doc. time - emphasis on sig. data - lower cost |
| Case Management Model | - Promotes coll., comm., teamwork and time - increased quality - focuses on outcomes - works best for typical pt. - |
| Computerized | - Assessment, care plans, adds new data, work lists, and doc. right at bedside - will be key component in using uniform definitions and common language |
| Electronic Medical Records | - data easily accessed, distributed, standardized |
Created by:
saraken2007
Popular Nursing sets