Patient documentation Flashcards
Who are are legally and ethically obligated to keep all patient information confidential
nurses
Nurses are responsible for protecting what?
medical records from ALL unauthorized readers
HIPAA requires that disclosure or requests regarding health information are limited to
the minimum necessary
STANDARD: HIPAA & NCQA
current documentations standards require each patient have an assessment
complete within 12-24 horus
confidential permanent legal documentation
records/charts
oral, written, or audiotaped exchange of info
reports
team members communicating in a group
conferences
what is essential within the health care team
interdisciplinary communication
a professional caregiver giving formal advice to another caregiver
consultations
arrangement for services by another provider
referrals
PURPOSE OF RECORDS
communication reimbursement research legal documentation education auditing/monitoring
Legal guidelines for recording
be factual correct all errors- one line only chart for yourslef no blank spaces time/date
Quality documentation:
Factual accurate complete current organized
Episode-oriented
Key information may be lost from one episode of care to the next.
Paper record
A digital version of a patient’s medical record
Integrates all of a patient’s information in one record
Improves continuity of care
electronic health record
The traditional method
narrative
Database
Problem list
Care plan
Progress notes
Problem oriented medical record
SOAPIE
subjective, objective, assessment, planning, intervention, evaluatioln
PIE
problem, intervention, evaluation
DAR
data, action, response
Focuses on documenting deviations
Charting by exception
who controls longterm care?
medicare and medicaid
Occurs with transfer of patient care
Provides continuity and individualized care
Reports are quick and efficient.
hand off report
Situation-background-assessment-recommendation (SBAR)
Document every call
Read back
Telephone reports/orders
