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Documentation
| Question | Answer |
|---|---|
| purpose of documentation | provides written record of history, treatment, care and response of the patient while under the care of a health provider |
| purpose of documentation | *guide for reimbursement of cost of care. *may serve as evidence of care in a court of law *shows the use of the nursing process *provides data for quality assurance studieS |
| how do insurance companies justify payments? | documentation of complication of a pt's changing condition are used |
| purpose of documentation * | serves as evidence of standards of care at a court of law. |
| baseline assessments | what is very important to have? |
| methods of documentation/charting | *source-oriented (narrative) charting *problem-oriented medical record (POMR) charting *focus charting *charting by exception *computer - assisted charting *case mgmt system charting |
| source oriented narrative charting * | focuses on patient's disease |
| POMR charting * | focuses on the problems experienced by the patient as a result of being ill or on the defined nursing diagnoses reflecting those problems |
| focus charting * | centers on the patient from a positive perspective |
| charting by exception * | focuses on deviations from predefined norms, using preset protocols and standards of care |
| computer-assisted charting * | where data are input to the computer |
| case mgmt system charting * | tracks variances from the clinical pathway |
| source oriented narrative charting | *organized accdg to source of info *separate forms for nurses, physicians, dietitians etc to doc assessment findings and plan the pt's care *requires doc of pt care in chronological order |
| source oriented narrative charting - advantages* | it includes all except it encourage normal and abnormal findings |
| source oriented narrative charting - DISadvantages* | makes it difficult to separate pertinent from irrelevant info; requires more time by staff; discourages health care team to read all parts of chart |
| POMR charting | *focuses on patient status rather than on medical or nursing care* 5 basic parts: db, problem list, plan, progress notes and discharge summary |
| POMR charting - advantages | * docs care by focusing on pt's problems * promotes problem solving approach to care *improves continuity of care and communication all in one place *allows easy auditing *requires constant eval |
| POMR charting - DISadvantages | *loss in chronological charting *more difficult to track trends in pt status |
| PIE CHARTING | follows the nursing process and uses nursing diagnoses while placing the plan of care within the nurses' progress notes |
| PIE | *P-problem identification *I-interventions *E-evaluation |
| focus charting | directed at nursing diagnosis, pt problem, sign, symptom or event |
| focus charting 3 components | DAR (data, action, response) or DAE (data, action, evaluation) |
| focus charting - advantages | *compatible with the use of nursing process *shortens charting time: many flow sheets, checklists *not limited to pt problems or nursing diagnosis |
| focus charting - DISadvantages | *if db insufficient, pt problems missed *doesn’t adhere to charting with focus in nxdx & experienced outcomeS |
| charting by exception | based on assumption that all standard of practice are carried out and met with a normal or expected response unless otherwise documented *long hand note is written only when the standard statement on the form is not met |
| charting by exception - advantage | * highlights abnormal data and pt trends and it enables the staff to see notation of changes in the pt's condition @ a glance |
| charting by exception - DIS advantage | requires detailed protocols and standards *requires staff to use unfamiliar methods of record keeping and recording |
| E.H.R. (Electronic Health Recorder) | computerized record of pt's history and care across all facilities and admissions |
| CPOE (computerized provider order entry) | provides efficient work flow *automatically routs orders to appropriate clinical areas |
| computer-assisted charting - advantages | quick communication among departments abt pt needs *electronic records can be retrieved very quickly *reimbursement for services rendered is faster and complete |
| computer-assisted charting - DISadvantages | sophisticated security system needed to prevent unauthorized personnel from accessing records |
| accuracy in charting | be specific and definite in using words or phrases that convey the meaning you wish expressed *words that have ambigous meanings and slang should not be used |
| case mgmt system charting | method of organizing pt care through an episode of illnes so clinical outcomes are achieved within an expected time frame and at a predictable cose *clinical pathway or interdisciplinary care plan takes the place of the nursing care plan |
| flow charts | mainly tools to track routine assessments, treatments and frequently care given. *a time saver but they do not eliminate narrative charting. |
| brevity in charting | sentences are not necessary *abbreviations, acronyms, symbols are acceptable to the agency used to save time and space |
| kardex | not part of the permanent medical record *quick reference for current info abt the pt & ordered treatments*usually consists of folded card for each pt in a holder that can be quickly flipped from on pt to another |
| info on kardex | *rm no, pt name, age, sex, admitting dx, dr's name *date of surgery *type of diet ordered *scheduled tests or procedures *level of activity permitted *notation on tubes, machines, etc *nxdx orders for assistive or comfort measures *list of meds *IV |
Created by:
jekjes
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