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documentation

chapter 17

QuestionAnswer
characteristics of effective documentation complete, accurate, concise, factual, organized, confidential
what is confidential for pt? name, address, reason of illness, treatments received, formation about past illness
breaches in pt confidentiality sending emails via pulic networks, discarding copies of pt information in trash cans, holding conversations that can be overheard, faxing confidential info to unauthorized persons
patients' rights see and copy their chart, update their health record, get a list of disclosurese, request a restriction on certain uses or disclosures, choose how to recieve health info
policy for receiving verbal orders record in medical record, read back the order to verify accuaracy, date and and note time orders were issued
duties of RN receiving telephone orders read orders back to practioner to verify, date and note time orders were issued
purposes of pt record communicate with other providers, care planning, research, education, legal documentation, reimbursement
purposes of recording data facilitate pt care, serve as a financial and legal record, help in clinical research
methods of documentation PIE charting, focus charting, electonic medical records
formats/types of nursing documentation inital nursing assessment, kardex, plan of nursing care, progress notes, flow sheets, discharge summary, home healthcare doucmentation, long term documentation
change of shift report consists of___________ id information about pt, current helath status, current orders, summary of pt, report on d/c status
reporting on pt can be done_________________________. face to face, telephone conversations, written messages, audio-taped, computer
ways to confer about pt care consultations, referrals, team care conferences, nursing care rounds
benefits of nursing informatics increase accuracy of documentation, improvment in workflow
computerized nursing care plans must first be individualized to each pt.
patient confidentiality limits conversations about pt care/info only to those caring for pt
Created by: N119