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Documenting (Freshm)
Documenting, Reporting, Conferring Chapter 17 Fundamentals
| Documenting | |
|---|---|
| Consistant with professional agency standards; complete, accurate, concise, factual, organized and timely, legally prudent, confidential per HIPAA | Characteristics of effective documentation |
| 2100 | 9pm |
| 2400 | midnight |
| 0300 | 3am |
| 1300 | 1pm |
| 0900 | 9am |
| All information about pts written on paper, spoken aloud, saved on computer (name address ss# insurance cards) are | Confidential |
| Documentation system in which each healthcare group records data on own separate form: admission sheet, admission nursing assessment, graphic sheet, flow sheet, narrative nurses notes, med. sheet, exam sheet, MD order sheet, MD progress notes, misc. forms | Source-orientated records |
| Narrative nursing notes that relate to how a patient is progressing toward expected outcomes; PIE, focus chart, CBE, flow sheets | Progress notes |
| Description of where the patient stands in relation to problems identified in record at discharge; documents any special teaching or counseling the patient recieved, including referrals | Discharge summary |
| Record orders, RBTO, Date, time, Doctor name, Your signature title | Duties of RN recieving a telephone order |
| Evidence based descriptions of behaviors that demonstrate knowledge, characteristics and skills that demonstrate _____ ____ | Critical thinking indicators |
| PMOR | problem-orientated medical record |
| Initial assessment, Kardex care plan, Plan of nursing care, critical collaborative pathways, progress notes, flow sheets, discharge/transfer summary, home health care documents, long term care documentation | Formats for nursing documentation (goes in permanent record) |
| Plan of nursing care involves | ADPIE |
| Typical patient (outcomes, interventions, with sequence and timing) | Critical collaborative pathways |
| Narrative nursing notes, PIE, focus chart, CBE, flow sheets | Progress notes |
| Routine aspects of documeneted care; Graphic, 24 h fluid balance, MAR, 24 h pt care records (acuity charting forms higher rank=more exp. nurse) | Flow sheets |
| Has reason for treatment, significant findings, treatment, condition on transfer and instrucitons | Discharge and transfer summary |
| OASIS | home health care document (outcome, assessment, information set. |
| Resident assessment Instrument | RAI Long term care documentation |
| Focus charting | DAR (data action response) |
| Has variance charting and collaborative pathways | Case management model |
| Shorthand of significant findings | CBE charting by exception |
| PHR | personal health record (pt does) |
| Contains: database by Doc. problem list #1 #2..., Plan of care 1 problem w/plans, progress notes w/ diagnosis and SOAPIER | Problem orientated medical records POMR |
| Problem intervention evaluation at each shift | PIE |
| Plan of care and progress notes of POMR contain | theraputic, diagnostic and education |
| Change of shift report, telephone/telemedicine, transfer/discharge, indcident, messengers (not good), audio tape, face to face, computer, text pagers are; | methods of reporting care |
| Shorthand method of documenting patient data that is based on well-defined standards of practice; only excpetions to these standards are documented in narrative notes | CBE charting by exception |
| Systematic problem solving; ID, data collection, hypothesis, plan, hypothesis testing, interperation results, evaluation resulting in revision or conclusion of study | Scientific problem solving |
| The written or typed legal record of all pertienint interactions with the patient ADPIE | documentation |
| To consult and refer; nursing care rounds (group of nurses visit selected patients individually at each patients bedside), Nursing and interdisciplinary team conferences are examples of | Conferring about care |
| It's benefits are: resident respond to indiviualized care, staff communication becomes more effective, resident and family involvement increases, documentaion becomes clearer | Benefits of RAI (resident assessment Instrument) |
| Specific resident responses for one or a combo. of minimum data set elements that ID residents who either have a risk for developing specific funcitonal problems and who require further evaluation using resident assessment protocols | Triggers of RAI (resident assessment instrument) |
| Documentation system organized according to the persons specific health problems; inculdes database, problem list, plan of care and progress notes | POMR problem orientated medical record |
| Descriptive record of the patients condition; inculdes patients response to interventions by health professionals, and patient progress toward goal achievement | Narrative notes |
| case management tools used to communicate the standardized, interdisciplinary plan of care for a paticular goup of patients; care guidelines and outcomes are specified for each day of the patients stay | Clinical/critical pathway |
| Contains narrative nursing notes; SOAPIER, PIE, focus charting, CBE, and flow charts | Progress notes |
| Review for accuracy, sign orders, date, time, name, title, pgr. # | policy for MD review of verbal orders (24 h response?) |
| This should only be done in an emergency, always RBVO date time MD name your name and title | Verbal orders |
| Specify how RAI is implemented specified in state operation manuals | Utilization guidelines |
| When patient first enters hospital to obtain baseline data | Comprehensive assessment |
| Recorded in intial database with nursing history, and physical | initial assessment |
| Communication, Diagnostic and theraputic orders, care planning, quality review, research, decision analysis, education, legal documentation, $, historical documentation | the reasons we document or patient records are formed |
| Are on seperate forms include all care give by different specalities; chronologically placed | Source-orientated records |
| POMR all health care specialities record on the same record, has a defiend database, problem list care plan and progress notes | Problem orientated medical records |
| DAR (data action response) This cart includes patient concerns, behaviors, therapies, responses, consults, monitoring, management of ADLs, or assessment of funcitonal health problems | Focus Patient care notes (DAR-data, action, response) |
| Based upon collaberative pathways and variance charting. A premade chart depending on Dx that outlines care. Cost effective timely, reflects the "typical group" | Case management models |
| Contains Database, problem list, care plans, progress notes | POMR problem orientated medical records |
| Contains SOPAIER | POMR (problem-orientated medical records) progress notes portion |
| What parts of POMR contain theraputic, diagnostic and educational aspects? | Care plans and progress notes (plan portion) |
| Includes expected outcomes, list of interventions and the sequence and timing of those events | Critical/collaborative pathways |
| This report has basic ID, current health status, changes in med. condition, response to therapy, where client stands r/t ID diagnosis/goals, Current nurse/MD orders, summary of ea new patient, report on transfers/discharged | SBAR change of shift report |
| A core set of screening clinical and comprehensive assessment of all residents in long term care facitlies certified to participate in meicare or meicaid. The items standardize communication about residents problems and conditions | Minimum data set RAI (resident assessment instrument) |
| Displaying, sending, sharing, discarding, holding conversations, faxing, sending can | Breach patient confidentiality |
| See and copy health record, update health record, get list of disclosures, request a restriction, certain uses or disclosures, choose how ot receive health information | Patient rights |
| Patient homebound and still needs care, Rehab. potential good, Hospice called, Pt not stablizied, Pt progressing in expected outcome of care | Medicare requirements for home healthcare |
| Documenation that is used in long term care that has a goal of quality of life and qualityof care; minimum data set, triggers, resident assessment protocol, utilization guidelines | RAI (resident assessment instrument) |
| Plan of nursing care that is a folded card placed in a central location where it is easily accessable outside basic information inside nursing care plan | Kardex care plan |
| Routine aspects of nursing care put on a | flow sheet |
| record of specific patient variables | graphic record |
| Communication method used by nurses who are completing care for a patient to transmit patient infoamtion to nurses who are about to assume responsibility for continuing care; may be exchanged verbally in a meeting or audiotaped | Change of shift report |
| Documentation metod in case management that records unexpected events, the cause of the event, actions taken in resoponse to the event and discharge planning whe appropirate | variance charting |
| Thought is disiplined, comprehensive based on intellectual standarsm, and as a reslut well reasoned a systematic way to form and shape ones thinking that functions purposfully, and exactingly | Critical thinking |
| Written plan that details the nrusing activities to be excuted in specific situations | protocol |
| documenta that details the nursing care to be implemented in specific nursing situations; frequently when MD is not present; may expand scope of nursing responsibilities | Standing orders |
| The nurse in PACU asses dressing for amt. consistency color of drainage, tube or drain amount type of drainage by that route | wound assessment |
| When one directly apprhends situation based on its similarity or dissimilarity to other situations.. You need experience for it to be accurate | Intuitive thinking |
| People prepare their own health records on the web to manage it | PHR personal health record |
| Set of assessment questions to collect clinical financial and administrative data in home health agencies. Goals to improve quality of care delivered to home health care patients to provide data to HCFA | OASIS (outcome assessment information set) (national quality incentive) |
| Problem intervention education | PIE chart |
| Doesn't develop a seperate plan of care. On assessment at the beginning of each shit the problems are ID and numbered, placed in the progress notes and worked up as the | PIE |
| Facilitate patient care, serve as financial and leagal record, help in clinical research , support decision analysis | Purposes of recording data |
Created by:
Cinderelle
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