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Flashcards in Quiz 2 documentation powerpoint Deck (31)
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Paper record

Key information may be lost from one episode of care to the next.


Electronic health record (EHR)

A digital version of a patient’s medical record
Integrates all of a patient’s information in one record
Improves continuity of care



story-like format. Weaknesses of the narrative format include repetition, length, and disorganization


Problem-oriented medical record (POMR)

organized according to the patient’s health care problems. Data are organized by problem or diagnosis.
Problem list
Care plan
Progress notes



Subjective, objective, assessment, plan



Subjective, objective, assessment, plan, intervention, evaluation



Problem, intervention, evaluation
PIE charting has no separate care plan. The plan of care is incorporated into the progress notes. Patient problems are documented and numbered and addressed by that number in the progress notes.


Focus charting (DAR)

Data, action, response
incorporates not only medical and nursing diagnoses but patient concerns and behavior, therapies, and responses.


Charting by exception—CBE

Only deviations from the well-defined standards of practice are documented. Decrease in charting time and emphasis on significant data are benefits.


Source records

A separate section for each discipline
separated into nursing, medicine, social work, and respiratory therapy. The advantage is that caregivers can locate each section in which to document entries. The disadvantage is that patients’ problems are distributed across the record, and the record does not show how information is related and care is coordinated to meet patients’ needs.


Case management plan and critical pathways

incorporates an interdisciplinary approach to documenting patient care. Critical pathways are interdisciplinary care plans that include patient problems, key interventions, and expected outcomes within an established time frame.
•Unexpected outcomes, unmet goals, and interventions not specified within the critical pathway time frame are called variances.


Critical Pathways

Multidisciplinary approach to document client care
Standardized POC summarized into pathways with a case management plan
1-2 page integrated care plan for problems
Key interventions + expected outcomes


Admission nursing history form

Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems


Flow sheets and graphic records

Help team members quickly see patient trends over time and decrease time spent on writing narrative notes


Patient care summary or Kardex

Many hospitals now have computerized syThe summary automatically updates as nurses stems that provide information in the form of a patient care summary that is often printed for each patient during each shift. make decisions, and data (e.g., orders) are entered into the computer.
•In some settings, a Kardex is kept at the nurses’ station. An updated Kardex eliminates the need for repeated referral to the chart for routine information throughout the day.


Standardized care plans

Preprinted, established guidelines used to care for patients who have similar health problems


Discharge summary forms

includes medications, diet, community resources, follow-up care, and whom to contact in case of an emergency or for questions


Acuity records

not part of a patient’s medical record. They are used for determining the hours of care and the staff required for a given group of patients


What to document

Your interventions w/ patient’s response and your evaluation
Any significant changes or events in condition
Informed consent
Patient teaching
Any attempts to contact medical staff
Patient leaving AMA
Patient’s refusal of treatment
Spiritual concerns
Use of restraints
Medication Administration


Hand-off report

Occurs with transfer of patient care
Provides continuity and individualized care
Reports are quick and efficient.


Home Care Documentation

Documentation in the home care system is different from that in other areas of nursing.
•Some parts of the record remain in the home with the patient; other information is needed in an office setting. Thus duplication of documentation is often necessary. Agency policies indicate which forms nurses need to leave at their office versus which forms must be taken into the homes.
•Evolving computerized patient records are making it easier for records to be available in multiple locations.


Long-Term Health Care Documentation

Long-term care documentation is interdisciplinary and is closely linked with fiscal requirements of outside agencies.
Increasing numbers of older adults and people with disabilities in the United States require care in long-term health care facilities.
•The goal is a system of clinical documentation that improves care for residents and increases reimbursement for that care.
The Omnibus Budget Reconciliation Act of 1987 includes Medicare and Medicaid legislation for long-term care documentation.


Telephone reports and orders

Situation-background-assessment-recommendation (SBAR)
Document every call
Read back


Incident or occurrence reports

Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient
Follow agency policy


Critical elements in an incident or occurrence report

Date/time of occurrence
How nurse found the client
Witness info
Assessment of client’s injury
Actions taken + FU notations
Who finds/witnesses the incident writes the report
Not part of the medical record


Examples of incidents

patient falls, needlestick injuries, a visitor having symptoms of illness, medication administration errors, accidental omission of ordered therapies, and circumstances that lead to injury or to risk for patient injury.


Health care information system (HIS):

a group of systems used in a health care organization to support and enhance health care
consists of two major types of systems: clinical information systems (CISs) and administrative information systems. Together the two systems operate to make the entry and communication of data and information more efficient.


patient identifiers

birth date, social security number, room number, or medical record number.


Purposes of Records

client education
legal documentation
financial billing/ reimbursement


Quality Guidelines for recording