Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
FON exam 3
documentation
| Question | Answer |
|---|---|
| if it wasn't charted... | it wasn't done |
| what time do most facilities use | military time to avoid confusion between AM and PM |
| documentation | written or electronic, legal record, all pertinent interactions |
| what is the medical record | compilation of the pts health information, a legal document |
| who owns what | paper is owned by the hospital content is owned by the pt |
| health insurance portability and accountability act (HIPPA) of 1996 | if a health institution wants to release a pts health information for purposes other than treatment, payment, and routine healthy care operations, the pt must be asked to sign an authorization |
| what are the exceptions to the HIPAA of 1996 | public health activities, law enforcement, deceased individuals |
| HITECH act of 2009 goal | to promote the meaningful use of health information technology |
| HITECH act of 2009 improves | quality, safety, and efficiency through digital security |
| strengthened HIPAA rules | penalties for data breaches, required notification of pts if there is a breach |
| HIPAA established pt rights to | see and copy their health records choose how to receive this copy update their chart obtain a list of disclosures |
| who uses the medical record | health care personnel, regulatory agencies, insurance companies, researchers, pt |
| what info is confidential | all info abt pts written on paper, spoken aloud saved on computer |
| potential breaches in confidentiality | info on a public screen sending emails via public networks sharing printers discarding copies in trash convos that can be overheard faxing to unauth ppl confidential messages transmitting any info via social media |
| incidental disclosure of PHI | secondary disclosure that can't reasonably be prevented, is limited in nature, and occurs as a by-product of an otherwise permitted use of disclosure of PHI |
| examples of acceptable incidental disclosure | sign in sheets pt charts outside the exam rooms white boards calling out names in waiting rooms leaving appt reminders in voicemails |
| HIPAA and social media | happens by posting pt photos or details stories with identifiable info comments in private groups that can be traced |
| consequences of HIPAA and social media | job termination, fines up to $50,000 per violation, loss of nursing license |
| what constitutes a HIPAA violation on social media | pt name, DOB, vehicle id, device serial numbers, full face images, any identifiers shown in a post picture or video |
| a violation does not | require the use of a pts name, a breach can occur if enough info is shared to reasonable identify the pt |
| who decides what to chart and what to format | professional standards, health care personnel, governmental agencies, accrediting bodies |
| all documentation must be | complete, concise, timely, accurate, factual unless quotes the pt stated, secure, confidential, legally sound and meet established standards |
| content-guidelines | record observations, not interpretations no generalizations use chronological order know professional standards docu treatments AND failure to treat |
| document in a timely manner!!! | if you forget to document something, record it as soon as you can indicate date and time of entry and of observations/intervention |
| what should you never do | document interventions before carrying them out! |
| when do we chart | upon admission, transfer to another unit, discharge shift assessment when a procedure is performed when you have pt post op when communicating with HCP for any change in pt status, follow policies of facility |
| format for paper guidelines | use appropriate forms write legibly with dark black ink never skip lines draw single line thru blank spaces, or error and then write intials use only accepted terms, abrv, and symbols sign your name (SN is title) |
| what should you never do when formatting on paper | use erasers or white out to correct mistakes |
| documentation error frequency | study audited medical records in primary clinics - 98% had some form of documentation problem national survey - 6.5% of pts requested corrections of errors in their medical records via patient portals |
| correcting errors | follow the correct protocol of your institution for correcting errors even if you delete the info, it still can be retrieved from the computer by the IT people |
| correcting a charting error on paper | draw one line through the error, date and initial the correction |
| correcting a charting error on electronic medical record (EMR) | make a new entry with today's date and time, stating your name and that you are correcting an error in a previous entry, give the date and time of the previous entry and enter the corrected data or explanation |
| for EMRs | create a secure password, never give out password or electronic signature to anyone, never leave the computer unattended if you are logged on, never send protected health information by email |
| documentation charting formats | narrative notes, charting by exception, focus charing, SOAP notes |
| narrative notes | nurse describes in their own terms the pts assessment, interventions and responses, should only be done for abnormal findings |
| cons of narrative notes | time consuming, difficult to read, and difficult to find specific information |
| SOAP notes | subjective, objective, assessment, plan |
| SOAP: subjective | what the pt states cannot be measured |
| SOAP: objective | measurable - VS, physical assessment |
| SOAP: assessment | what is wrong with the pt based on subjective and objective assessments |
| SOAP: plan | plan of care/treatment pt education physician consult |
| what stands out abt poor quality charting | inaccurate, repetitious, omissions, illegal abbreviations, judgmental terms, general terms |
| TJC "do not use" list | unacceptable abbreviations spell out units (not u or U) spell out daily (not qd) no trailing zero (not 1.0mg, just 1mg) always use leading zero (0.1mg) |
| what are the results of poor charting | lower the quality of pt care, reflect poorly on the individual and nursing profession, legal issues |
| what makes charting so difficult | computer issues, interruptions, prioritizing pt needs vs documentation |
| how can i improve my charting | solicit feedback, document ASAP, document all calls |
| how should RN document verbal and telephone orders | write it out, read it back, not the modality, write the full name of the physician, sign or e-sign the orders with name and title and "read back" |
| charting medical errors | exact details should always be included in the chart, notification of pt and family completed and charted, never chart that an occurrence report was completed |
| incident report | used to document an occurrence out of the ordinary that could or has caused pt harm, used for quality improvement, provide exact details, witnesses, safety measures in place to prevent, follow up measures, effectiveness of interventions, not part of EMR |
Created by:
leh195