Documentation Flashcards
purpose of documentation (8)
communication
education
assessment
research
auditing
legal documentation
agency accreditation
Reimbursement
Flow Sheets:
Definition:
advantages (3)
Definition: Flow sheets are structured, grid-like forms used to document specific parameters over time, such as vital signs, intake/output, pain levels, or glucose readings.
Advantages:
Structured Format: Provides a standardized way to document essential patient data, ensuring consistency.
Quick Overview: Allows for a quick overview of trends in vital signs or other parameters.
Easy to Read: Information is presented in a clear and organized manner.
- Electronic Documentation: ( define/ advantages 4)
Definition: Electronic documentation involves the use of electronic health records (EHR) or computerized systems to input and store patient information.
Advantages:
Efficiency: Streamlines documentation, reducing redundancy and saving time.
Accessibility: Allows multiple healthcare providers to access patient records simultaneously, promoting interdisciplinary communication.
Data Integration: Can integrate data from various sources, providing a comprehensive view of the patient’s health status
.
Decision Support: May include alerts and reminders for medication interactions, allergies, or preventive care, enhancing patient safety.
Source-Oriented Documentation:
define
characteristics (1)
advantages (2)
disadvantages (2)
Definition: is a traditional method where different healthcare professionals maintain separate sections of the patient’s medical record. Each department or discipline contributes information in their designated section.
Characteristics: Information is grouped by the source or department, such as nursing notes, physician orders, laboratory reports, and radiology reports.
Advantages:
Specialization: Each healthcare provider can focus on documenting specific aspects of care.
Familiarity: Clinicians are accustomed to this traditional approach.
Disadvantages:
Lack of Continuity: It can be challenging to follow the chronological order of events and understand the patient’s overall status.
Inefficiency: Requires professionals to review multiple sections to get a comprehensive view of the patient’s condition.
Problem-Oriented Documentation:
define
characteristics (2)
advantages (3)
disadvantages (2)
Definition: organizes patient information around specific healthcare problems or issues. It emphasizes the systematic identification, analysis, and resolution of patient problems.
Characteristics:
Patient problems are identified and listed, serving as a focal point for documentation and care planning.
SOAP Format ( Subjective data, Objective data, Assessment, and Plan) . Each problem is documented using this structured format, ensuring consistency and organization.
Encourages collaboration among healthcare providers to address specific problems.
Advantages:
Holistic View: Provides a comprehensive and organized overview of the patient’s problems, treatments, and progress.
Collaboration: Facilitates communication and collaboration among healthcare providers by focusing on shared patient problems.
Disadvantages:
Learning Curve: Requires training and adjustment for healthcare professionals accustomed to source-oriented documentation.
Initial Time Investment: Setting up the problem list and initial assessment requires dedicated time and effort.
we always document chronically
t or f
t
_______________ is favored when an interdisciplinary team is involved in the patient’s care, ensuring a shared focus on resolving patient problems.
Problem-oriented documentation
Outline sequence used in charting (7)
- Patient Identification:
**2. ** Subjective Data (S):
Patient’s Description:
**3. ** Objective Data (O):
**4. ** Assessment (A):
.
**5. ** Plan (P):
I
**6. ** Response/ Evaluation:
**7. ** Signature and Credentials:
Sign and Date: Sign the entry with your full name and credentials (e.g., RN for registered nurse).
Authentication: Some systems may require additional authentication steps, such as entering a password or using an electronic signature.
The standard of care refers to
for care /charting to be judged, it will be compared to expected levels of care. detailed guidelines that represent the predicted care indicated in specific situation .
they describe nursing care and define professional practice . They define interventions for which nurses are held legally accountable.
“care pathways”/ critical pathways”
sources of standard for nursing documentation (5)
Federal Statutes ( medicare/aid)
state statues (nurse practice act, department of health )
ANA
joint commmison on accreditation (jacho)
institutional policy and procedure
When to document (10)
*1. ** Immediately After Care:
**2. ** During or After Assessments:
Assessment Findings:
**3. ** After Medication Administration:
Medication Administration Record (MAR): **4. ** Following Procedures or Interventions:
terapies, wound care, and patient responses to these interventions.
**5. ** Changes in Patient Condition:
**6. ** After Patient Education:
**7. ** Critical Events or Incidents:
**8. ** Before Shift Change:
**9. ** At Discharge or Transfer:
**10. ** Regularly and Consistently:
Special rules for paper charting (6)
a. maintain HIPAA
b. Correctly labeled
c. date + time all entries
d. write legibly
e. black ink
f. no blank lines
g. Correction of Errors:
No Erasing: Do not use erasers or correction fluid to correct errors. Instead, draw a single line through the incorrect entry, write “error” or “mistaken entry,” and sign your name and date the correction.
Avoid White-Out: Do not use white-out, as it can obscure information and raise concerns about tampering.
kardex
brief overview of pt
Special rules of emr (5)
a. hipaa
b. DONT SHARE PASSWORD
c. follow policy for errors
d. flow sheets and form built in
e. dont bypass safety features
Nursing Formats ( 3)
a. be aware of unsafe abbreviations \
b. narrative notes
c. focus charting
