Chapter 3 Flashcards
Chart health care record had never been ?
more important in the health care system than today
The process of adding information to cart is called charting ,recording,documenting what’s different ?
Documenting involves recording the interventions carried out to meet patient care .
Charting of intervention the time care was rendered and signature and title of the person provided care essential
What are the five basic purpose for accurate and complete patient ?
•Documented communication
Permanent record for accountability
-Legal record of care Teaching Research and data collection
•Audits (part of the continuous quality improvement process that focus on specific issues or aspects of health care and clinical practice)
•Diagnosis-related groups (DRGs)
•Nurses’ notes
Electronic health record (EHR) and Personal Health Record (PHR) ?
1.use of the record
2.ease of use documentation
3. Point of care
4. Computer is wheels (cow)
5. Security
What does patient chart provide?
Concise ,accurate, and permanent record of past and current medical and nursing problem ,plans for care , care given , patient response various treatments
Current regulations require chart audits?
Review of specific chart components for completion and appropriateness officially appointed auditors (people appointed to examine patient charts and health records to assess quality of care )
Current regulations require chart audits?
Review of specific chart components for completion and appropriateness officially appointed auditors (people appointed to examine patient charts and health records to assess quality of care )
Institutions have medical and peer review?
An appraisal by professional coworker of equal status
Institutions also have specific procedures to provide for quality assurances,assessment, and improvement which is ?
Audit in health care that evaluates services provide and results achieve compared with accepted standards
What does SBAR stand for ?
Situation, background, assessment, and recommendation
-Communicates between provider and nurse, nurse and nurse
-Joint Commission states “it meets the National Patient Safety Goals”
What are the basic guidelines for documentation?
-Quality and accuracy of the nurse’s notes are extremely important
-Correct spelling, grammar, and punctuation, as well as good penmanship and other writing skills are important in documentation
-Information recorded in the chart should be clear, concise, complete, and accurate
Methods of Recording Documents
?
1.Traditional chart ( is divided into section or blocks ,emphasis is placed on specific section of sheet )
2.Narrative Charting (Nurses uses a flow sheet ,graphic recording of patient care in descriptive form )
3.Problem-oriented medical record (POMR) according to the scientific problem solving system or methods ( the accumulated date or database from history,physical exam)
4.Focus charting
5.Charting by exception
6.lternative forms
7.Kardex/Rand Nursing care plans
kardex or Rand system is used by some facilities to consolidate patient order and card needs a centralized ,concise way
Nursing Plan which outline the process of nursing care based on the nursing assessments to identify patient problems
The four document forms are ?
1.Incident reports ( for example if a nurse neglects to give medication or treatment or gives an incorrect dose of drug ,an incident report)
- Twenty-four hour patient care reports
3.Acuity form (use a score that rates each patient by severity of illness )
- discharge summary form
Home health Care documentation ?
- Documentation provides quality control and reimbursement from Medicare, Medicaid, and private insurance companies
-Must note patient education a demonstration of Learning
-Coordination of services and compliance of regulation reflected by all
Long-Term Health Care Documentation?
-Omnibus Budget Reconciliation Act (OBRA) of 1987 regulates standards for resident assessment, individualized care plans, and qualifications for health care providers
-Department of Health (DOH) for each state governs frequency of written nursing records of residents
-Supports multidisciplinary approach in assessment and planning processes of patient care
What are the special issues in documentation?
-Record ownership and access
-Confidentiality ( health care personnel are required to respect the confidentiality of the patient record )
-Electronic Documentation (efficient method of documentation, Some computer system online access from remote site
-Use of Fax Machine (health Insurance Portability and Accountability Act HIPAA allow for patient medical record and information to be faxed
What are the elements of documentation?
1.Factual Subjective date ( direct quotes, within quotation marks, or summarize) Objective Date ( should be descriptive and should include what the nurse sees,hears, feels and smells
- Accurate and Concise(document facts and information precisely (what the nurse see, heart,feels,smell)
3.Complete and Current
4.Organized
