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Documentation for NU112

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