Question | Answer |
Documentation | - Written or typed record of all pertinent patient interactions facilitating patient care. |
Patient Record | - Compilation of a patient's health information, nursing information, nursing responsibilities policy, follows professional standards and local polices. |
JCAHO
Specifications | - Assessment diagnosis/patient needs, interventions and outcomes.
- Permanent legal record and is best def.
- Omissions, Repetition, inaccuracies, cause legal problems. |
Content | - Complete, accurate, professional, specific, precautions/prevention, responsive, legally prudent, avoid inappropriate terms. |
Timing | - Prompt
- date/time, military time
- never predocument |
Format | - right chart/patient information
- follow policy
- legible/grammar/spelling
- use acceptable terminology, abbreviations - - never skip lines, draw a line through blank spaces |
Accountability | - First initial/last name/title
- no dittos/erasures/correction fluid
- use "mistaken entry" or error in charting"
- identify each page with pt. Name/ID #
- Permanent/complete |
Confidentiality | - Follow Policy/legislation
- professionally and ethically bound |
What
is
Confidential | - All Patient information written, spoken, and computerized
- Name
- Address
- Phone/fax
- S.S. Number
- Illnesses/Treatments
- Information about past health conditions |
Potential
Violations | - Info displayed on screen
- public email, facebook, etc.
- shared printers
- use marker on trash
- inappropriate conversation
- faxing
- overhead paging
- failure to log off
- improper access, review or release |
HIPAA | - Health Insurance Portability and Accountability Act
- See and copy health record
- Update Health Record
- List of Disclosures
- Restrict uses or disclosures
- Choose how to receive health information |
When is
Authorization
Not needed | - Treatment
- Payment
- Routine healthcare operations |
Permitted
Disclosure | - Public Health-Disease outbreaks
- Infection control
- Stats of dangerous drugs/devices
- Law enforcement
- disaster victims
- Child abuse, neglect, domestic supoena
- Low organ donation, death in a crime |
Incidental
Disclosures | - Sign in Sheets
- Confidential interviewing
- Patient carts outside rooms
- White Boards
- X-ray light boards
- appointment message reminders |
Verbal
Orders | - Medical Emergency
- Received by RN or pharmacist who documents and executes order, date & time
- Reads back to verify accuracy
- Record VO, name of practitioner nurses name and initials and title |
More on
Verbal
Orders | - responsible to review for correctness sign name/title/pager number, date & time within a specific time,
- restraints, narcotics, anticoagulants, and antibiotics within 24 hours
- Questionable orders have another RN listen |
Documentation
Methods | - Source-orientated
- Problem-orientated
- PIE
- Charting by exception
- Case management
- Computerized
- electronic Med. Records |
Source-Orientated
Documentation | - Is filed by group(physicians, nurses ,lab)
- each one can easily find but fragmented |
Problem-Orientated
Documentation | - POMR - Problem orientated medical record
- organized around patient problem
- all HCPs use the same form
- SOAP notes (subjective, objective, assessment, plan) |
PIE
Documentation | - Problem, Intervention, Evaluation
- incorp. paln of care into progress notes
- problems are id by number
- complete assessment done each shift |
Foucs
Documentation | - holistic care is focused on patient using narrative DAR (Data, action, response) |
Charting
by
Exception | - Short hand documentation of sig. Findings.
- lower doc. time
- emphasis on sig. data
- lower cost |
Case
Management
Model | - Promotes coll., comm., teamwork and time
- increased quality
- focuses on outcomes
- works best for typical pt.
- |
Computerized | - Assessment, care plans, adds new data, work lists, and doc. right at bedside
- will be key component in using uniform definitions and common language |
Electronic
Medical
Records | - data easily accessed, distributed, standardized |