Documentation for NU112
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| Documentation | - Written or typed record of all pertinent patient interactions facilitating patient care.
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| Patient Record | - Compilation of a patient's health information, nursing information, nursing responsibilities policy, follows professional standards and local polices.
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| JCAHO Specifications | - Assessment diagnosis/patient needs, interventions and outcomes.
- Permanent legal record and is best def.
- Omissions, Repetition, inaccuracies, cause legal problems.
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| Content | - Complete, accurate, professional, specific, precautions/prevention, responsive, legally prudent, avoid inappropriate terms.
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| Timing | - Prompt
- date/time, military time
- never predocument
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| Format | - right chart/patient information
- follow policy
- legible/grammar/spelling
- use acceptable terminology, abbreviations - - never skip lines, draw a line through blank spaces
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| 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
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| Confidentiality | - Follow Policy/legislation
- professionally and ethically bound
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| What is Confidential | - All Patient information written, spoken, and computerized
- Name
- Address
- Phone/fax
- S.S. Number
- Illnesses/Treatments
- Information about past health conditions
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| 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
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| 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
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| When is Authorization Not needed | - Treatment
- Payment
- Routine healthcare operations
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| 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
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| Incidental Disclosures | - Sign in Sheets
- Confidential interviewing
- Patient carts outside rooms
- White Boards
- X-ray light boards
- appointment message reminders
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| 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
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| 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
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| Documentation Methods | - Source-orientated
- Problem-orientated
- PIE
- Charting by exception
- Case management
- Computerized
- electronic Med. Records
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| Source-Orientated Documentation | - Is filed by group(physicians, nurses ,lab)
- each one can easily find but fragmented
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| Problem-Orientated Documentation | - POMR - Problem orientated medical record
- organized around patient problem
- all HCPs use the same form
- SOAP notes (subjective, objective, assessment, plan)
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| PIE Documentation | - Problem, Intervention, Evaluation
- incorp. paln of care into progress notes
- problems are id by number
- complete assessment done each shift
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| Foucs Documentation | - holistic care is focused on patient using narrative DAR (Data, action, response)
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| Charting by Exception | - Short hand documentation of sig. Findings.
- lower doc. time
- emphasis on sig. data
- lower cost
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| Case Management Model | - Promotes coll., comm., teamwork and time
- increased quality
- focuses on outcomes
- works best for typical pt.
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| 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
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| Electronic Medical Records | - data easily accessed, distributed, standardized
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