Documentation & Reporting Flashcards
______________ among health professionals is vital to the quality of client care. .
effective communication
Health personnel communicates through _______, ________, and _______
- discussion
- reporting
- recording
Documentation is defined as a written evidence of:
● __________ between and among health professionals, clients, their
families, and health care organizations
● the __________ of tests, procedures, treatments, & client education
● ________ or ________ to these diagnostic tests & interventions
- interaction
- administration
- results/ client’s response
it is an exchange of information about clients among health team members, clients, and family members.
reporting
it is an oral, written, or computer-based communication intended to convey information to others
report
an action of documenting information relevant to the client’s health care management
recording
it is a chart or client rec formal, legal document that provides evidence of a client’s care
○ can be written or computer-based
record
It means that the elements of the nursing process are evident in the documentation.
quality documentation
what are 3 Quality Documentation indicators
- Reflects the application of the nursing process
- Critical inquiry emphasizing critical thinking and clinical judgment skills
- Consultations and referrals, including provider’s full name, designation and organization
one of the indicators of quality documentation is reflecting of the application of the nursing process and it includes:
a. ___________, interpretation of findings (analysis) and diagnosis,
subjective and objective data.
b. ___________ which takes into account the clients’ needs, circumstances, preferences, values, abilities and culture, and supports the client in self-management of care
c. ___________ of intervention
d.____________ and ___________ of the care plan.
- assessment,
- plan of care
- implementation
- evaluation, modification
what are the purposes of health care documentation
it helps in:
- communication
- education
- research
- legal and practice standards
- planning client care
- auditing health agencies
- reimbursement
one vital purpose of health care documentation is the nurse’s ability to clearly communicate all important information regarding the client
communication
Nurses use the documented data for learning and enhancing critical thinking while providing confidentiality that must be strictly practiced.
education
Information contained in the client record can be a valuable source of data for________
research
failure to document can lead to clinical mishaps à malpractice
cases
legal and practice standards
information in client records can help in the treatment process as well as improve the delivery of nursing care.
planning client care
review of client records for quality assurance purposes
auditing health agencies
helps a facility receive reimbursement from the government (PhilHealth), for a facility to obtain payment.
reimbursement
what are the different documentation systems that nurses and hospitals use.
- source-oriented records
- narrative charting
-POMR (problem-oriented medical record)
-FDAR (focus, data, action, response) - charting by exception
- computerized documentation
a type of documentation where each department have their own forms or sections in the client’s chat
source-oriented records
__________ - admission dept.
___________ - used by primary care provider
___________ - primary care provider
___________ - nurses (FDAR)
● Admission sheet
● Physician’s notes
● Progress notes
● Nurses notes
It is convienient documentation system because care providers from each discipline can easily locate the forms on which to record data and it is easy to trace the information specific to one’s discipline.
source-oriented records
It is a traditional part of the source-oriented record. It consists of _______ notes that include routine care, normal findings, and client problems.
- narrative charting
- written
it is a documentation system that its content is the same as FDAR but in paragraph form
narrative charting
the data are arranged according to the problems the client has rather than the source of the information.
POMR (problem oriented medical record)
the advantages of POMR are:
● encourages _________
● _________ in the _______of the chart alerts caregivers to the client’s needs and makes it easier to track the status of each problem.
- collaboration
- problem list, front
the disadvantages of POMR are:
● caregivers differ in their ______ to use the required _________
● it takes __________ to maintain an _________ problem list
● it is somewhat _______ because assessments and interventions that apply to more than one problem must be repeated.
- ability, charting format
- constant vigilance, up to date
- inefficient,
the POMR has 4 basic components which are
- database
- problem list
- plan of care
- progress notes
In POMR, all information known about the client upon admission, includes the nursing assessment, history, social and family data, results of PE and baseline diagnostic tests
database
In POMR, this part is kept in front of the chart, listed in the order in which they are identified, all caregivers may contribute to the problem list
problem list
in POMR, Primary care givers write physician’s orders or medical care plans, nurses write nursing orders or nursing care plans
plan of care
in POMR, it is a chart entry made by all health professionals involved in a client’s care
progress notes
