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DOCUMENTATION
| Question | Answer |
|---|---|
| DOCUMENTATION | act of recording pertinent medical information in a patient’s medical record, which may be handwritten on a paper chart or keyboarded into an electronic medical record |
| What are the 4 Purposes of a Patient Chart | 1.. pertinent data to all health care team mem for continuity of care2. perm record of med dx, nursing dx, care plan, pt response. 3. accountability for QA and Reimbursement. 4. Serves a legal record for both pt and health care provider |
| CONTINUITY OF CARE | For patient care to be effective, it must be delivered and evaluated continuously, systematically, and smoothly from 1 hour to the next, including through the staffing changes between shifts. |
| WHOSE MEDICAL RECORD IS IT | the original written or computerized medical record, even though it is about the patient, is the property of the hospital or facility |
| CONFIDENTIALITY | is the maintenance of privacy by not sharing with a third party privileged or entrusted information |
| INCIDENT REPORT | Written Report of an accidents, incident or mistakes |
| VARIANCE REPORT | This report is used to document out-of-the-ordinary things that happen in a facility. |
| Source-Oriented Records | organized by the source of the data |
| Problem-Oriented Records | organized around the patient’s individual problems rather than where the data came from |
| EHR | record of lifetime health information, interactions with health care system, record tests, appts, medications, signs and symptoms, diseases, immunizations, and allergies |
| KARDEX | which contains written data and is used for quick reference about each resident’s care. |
| GUIDELINES FOR PAPER DOCUMENTATION | only use Black/Blue ink, write neatly and legibly, sign each entry, include date, time with each entry, chronological order, entry in timely manner, use punctuation, do not leave blank lines, correct mistaken entries-never use white out |
| SUCCINCT CHARTING | make entries brief concise and to the point |
| HOW OFTEN IS UPDATE ON CONDITION NOTE IN LTC | once a week, Weekly Summary-as it is there residence |
| WHEN IS DAILY DOCUMENTATION REQUIRED ON PT IN LTC | When acutely ill and then once back to normal can go back to weekly |
| Admissions Assessment in LTC is required by | Medicare and Medicaid Requirements for certification and reimbursement |
| What is OBRA | Omnibus Budget Reconciliation Act |
| What does OBRA do | mandates that an extensive assessment form called the Minimum Data Set (MDS) for Resident Assessment and Care Screening must be completed for each resident within 4 days of admission to the facility and updated every 3 months. |
| What is MDS | Minimum Data Set (MDS) for Resident Assessment and Care Screening. |
| What are Timelines for MDS | 4 days of admission to the facility and updated every 3 months |
| What is in the Weekly Assessment in LTC | use of all protheses, activity level, elimination control and habits, nutrition vs malnutrition, ability to communicate, visitors and support system, social activities, ability to perform ADL's |
| What is OASIS | Outcome and Assessment Information Set, |
| Where is OASIS used | Home Health Agencies |
| Who Completed the OASIS | RN |
| 5 Documentation Mistakes that put you at Risk for Malpractice | Failure to document assessment findings, med administration, pertinent Health History, Physicians Orders, Documenting on wrong chart or MAR |
| charting by exception | which limits charting to only abnormal findings, situations, conditions, or results. |
| SOAP/SOAPIER | Can be used with source-oriented or problem-oriented records. Stands for Subjective data, Objective data, Assessment data, Plan/Intervention, Evaluation, and Revision |
| PIE | Addresses patient’s problems and what is done to solve them. Seen mostly in nurse’s notes. Stands for Problem, Intervention, and Evaluation |
| focus | Focused on patient and less structured than PIE. A common type is DAR, which stands for data, action, and response |
| Narrative | No set formula is followed; rather, the health-care professional writes a detailed account of the care the patient receives and events that occur in chronological order Most thorough but most time-consuming type of documentation |
| Charting by Exception | Notes written by health-care providers that focus only on abnormal findings; normal findings are not charted, and checklists are used for routine care Works best with EHRs |
| Methods of Charting | Charting by Exception Narrative focus pie soap/soapier |
Created by:
danpol1775