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CMIE chs 5-7
useless for anyone else but me!
| 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 |
Created by:
nursingstudent
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