chapter 26: informatics and documentation Flashcards Preview

foundations > chapter 26: informatics and documentation > Flashcards

Flashcards in chapter 26: informatics and documentation Deck (22)
Loading flashcards...
1

documentation

- vital aspect of nursing
- must document all care provided

nursing documentation systems
- reflect currect standards of nursing practice and minimize the risk of errors
- flexible to allow members of the health care team to efficiently document and retrieve clinical data, track pt. outcomes, ad facilitate continuity of care

2

purpose of health care record

- interprofessional communication
- legal record of care provided
- justification for financial billing and reimbursement of care
- auditing, monitoring, evaluation of care
- education and research

3

interprofessional communication within the medical record

- quality of pt. care depends on your ability to communicate with other members of team
- when a plan is not communicated to all members of the health care team, care becomes fragmented, tasks are repeated, and delays or ommissions in care often occur

4

communication within the medical record

legal documentation
- accuracy is one of the best defenses for legal claims

reimbursements
- clarifies treatment rendered

auditing and monitoring
- improved quality of care

education
- helps anticipate care needed for the pt.

research

5

what did HITECH establish?

provisions to promote the meaningful use o health info technology to improve the quality and value of health care

6

what will implementing EHR across the health care system do

decrease costs and improve the quality of pt. care

7

EHR

attributes, components and advantages

8

legal risk of electronic documentation

- combination of logical and physical restrictions to protect info
- computers in restricted areas
- privacy filters

9

disposing of info

- safeguard any info that is printed
- destroy when no longer needed
- de-identify all pt. data
- special considerations for faxing

10

guidelines for quality documentation

factual
accurate
current
organized
complete

11

methods of documentation

flow charts
progress notes
charting by exception

12

record-keeping forms within the ehr

- admission nursing history form
- pt. care summary
- care plans
- discharge summary forms

13

documentation communication with providers and unique events

- telephone calls made to a provider: document every phone call you to make to the health care provider

- telephone and verbal orders: use of VOs is discouraged except in urgent or emergent situations

- incidence or occurrence reports: not consistent with the routine, expected care of a pt. or the standard procedures in place on a health care unit within an agency

14

acuity rating systems

- determine the hours of care and number of staff required for a given of pt. every shift or every 24 ours
- based on type and number of nursing interventions required by a pt. over 24-hr period

15

acuity level

the classification used to compare one or more pt to another group of pt.

16

documentation in the long term health care setting

- documentation is governed by individual state regulation, tjc and cms
- CMS: mandates use of the RAI, including the MDS and CAA

17

documentation in the home health care setting

- medicare has specific guidelines to establish eligibility for home care reimbursements
- documentation is the quality control and the justification for reimbursement
- two different data sets set to document clinical assessments and care provided
- OASIS
- Omaha system

18

case management

incorporates an interprofessional approach to delivery and documentation of pt. care

19

critical pathways

interprofessional care plans that identify pt problems, key interventions, and expected outcomes within an established time frame

20

variances

unexpected outcomes, unmet goals, and interventions not specified within a critical pathway

21

informatics and information management in health care

- health care info system
- clinical information system
- nursing clinical info systems
- clinical decision support system

22

nursing informatics

integrates nursing science, computer science, and information science to manage and communicate data, info, knowledge, and wisdom in nursing and informatics practice