documentation Flashcards
(15 cards)
Purposes of the patient record?
communication, auditing and monitoring, research, legal documentation, reimbursement, and education.
EHR
electronic health record EHR- is a digital version of patient data that is found in traditional paper records. The term EHR is used increasingly to refer to a longitudinal (lifetime) record of health care encounters for an individual patient.
PHI
protected health information.
describe the guidelines for effective communication.
factual, accurate, complete and current.
narrative form of communication-
Narrative documentation tends to be time consuming and repetitious. It requires the reader to sort through a lot of information to locate desired data. However, some nurses believe that in certain situations use of this method provides better detail of individual patient assessment and findings and/or complex patient situations.
Problem-oriented form of communication-
The problem oriented medical record POMR is a system of organizing documentation to place the primary focus on patients’ individual problems.
Charting by exception form of communication-
CBE Is that a patient meets all standards unless otherwise documented. “Normal findings”
Case management model form of communication-
The case management model of delivering care incorporates an interprofessional approach to documenting patient care. Critical pathways- are interprofessional care plans that identify patient problems, key interventions, and expected outcomes within an established time frame. For example in cancer care some pathways focus on malignancies that have a higher incidence such as breast, colon, prostate, and lung cancers and certain types of blood cancers.
Admission history-
Completion of this form provides baseline data that you use for comparison when a patient’s condition changes.
Flow sheets and graphic records-
acute and critical care nurses commonly use flow sheets and graphic records to document physiological data and routine care. Within a computerized documentation system these forms allow you to quickly and easily enter assessment data about a patient such as vital signs, admission and or daily weights, and percentage of meals eaten.They also facilitate the the documentation of the provision of routine, repetitive care such as hygiene measures, ambulation, and safety and restraint checks. These documents provide current patient information accessible to all members of the health care team and help team members quickly see patient trends over time.
Patient care summary-
The document automatically updates and provides the most current information that has been entered into the EHR and usually includes the following information:
Basic demographic data
Health care provider’s name
Primary medical diagnosis
Medical and surgical history
Current orders from health care provider
Nursing care plan
Nursing orders
Scheduled tests and procedures
Safety precautions used in the patient’s care
Factors that affect patient independence with activities of daily living
Nearest relative or person to contact in an emergency
Emergency code status DNR
allergies.
Standardized care plans-
CPG- to facilitate the creation and documentation of a nursing and or interprofessional plan of care. Each cpg facilitates safe and consistent care for an identified problem by describing or listing institutional standards and evidence-based guidelines that are easily accessed and included in the patient’s EHR. Most computer systems allow CPG’s to be modified, allowing you to individualize interventions, goals, and or outcomes for each patient. Standardized care plans are useful when conducting quality improvement audits
discharge summary-
Ideally discharge planning begins at admission. By identifying discharge needs early, nursing and other health care professionals begin planning for discharge to the appropriate level of care, which sometimes includes support services such as home care and equipment needs.
Discuss the importance of acuity rating systems-
Nurses use acuity ratings to determine the hours of care and number of staff required for a given group of patients every shift or every 24 hours. A patient’s acuity level, usually determined by assessment data entered into a computer program by a registered nurse, is based on the type and number of nursing interventions (IV therapy, wound care, or ambulation assistance.) required by a patient over a 24 hour period. Acuity ratings are not part of a patient’s medical record, nursing documentation within the medical record provides evidence to support the assessment of an acuity rating for an individual patient.
Nursing informatics
s broadly defined as the use of information and computer technology to support all aspects of nursing practice, including direct delivery of care, administration, education, and research.
