Week 2: information technology, delegations, supervision, nsg process Flashcards
Information Technology
Chart or medical record, a legal record of care
- medical record is confidential, permanent, and a legal document valid in court
-nurses document reflecting the nsg process
Documentation**
Joint Commission mandates computerized databases
med rec includes- communication, legal docs, financial billing, edu, research, auditing
-reporting is to provide care amount team members
-reporting must be confidential
Elements of documentations**
types of data
factual: subjective and objective data
Subjective data- as direct quotes within quotation marks, or summarize and identify the information as the clients statement. subjective data need to be supported by objective data, chart descriptively
-Objective data- descriptive, (what nurses see, hear, feels, and smells). is never judgmental/derogatory “client paced back and forth, yelling loudly” vs “ client was angry”
Elements of documentation
Accurate and concise:
-use abbreviations/ symbols approved by Joint Commission and the facility
Complete and Current”
-is comprehesive, timely, DO NOT pre-chart
Organized:
Documentation Legal Guidelines
-start entry with date/time
-be legible, use non-erasable black ink
-no blank spaces in nsg notes
–no correction fluid, erase, scratch out, blackening of errors
-to make corrections follow facility guidelines
-sign all documents as the facility requires with names and title
-document your assessments, interventions, and evaluations, without any staff opinion
Documentation formats
Flow Sheets: show trends (vitals, blood glucose levels, pain level) very often assessed
Narrative Documentations: sequence of events is story-like
Charting by Exceptions” uses standardized forms that identify norms and allows selective documentations of deviations from those norms
Documentation using problem-oriented medical records
-organized by problem or diagnosis and consists fo a database, problem list, care plan, and progress notes
Examples:
SOAP, PIE, DAR
SOAP
Subjective data
Objective data
Assessment
Plan
DAR
Data
Action
Response
PIE
Problem
Intervention
Evaluation
Electronic health records
ar replacing manual formats
ADVANTAGES: standardization, accuracy, confidentiality, easy access for many users, easy to add on info, and easy to transfer info between facilities
DISADVANTAGES: learning the system, knowing how to correct errors, SECURITY
Change of Shift Report
-at end of shift to the oncoming nurse
-face-to-face or during rounds in each client’s room (unless the Pt is not alone)
Is Effective:
1 significant to Pt health
2. logical sequence
3. any changes in meds, Tx, procedures, and discharge plan
4. no gossip
telephone report
-useful to contact provider/another care member
IMPORTANT to
-have data ready before calling
-professional tone
-exact, relevant, and accurate data
*-Document the name of the person who made the call, who was given the information, the time, the contents of the message, and the instructions or information received during the report
Telephone/verbal Prescriptions *
-best to avoid, but can be necessary
-**have a second nurse listen
-Repeat it BACK, include the med name, dose, time, route (spell if needed)
-question any med that seems not appropriate
-make sure provider signs the prescription in person within the time frame the facility specifies (24 hrs)
Transfer Reports
-include demographic ifno
-med Dx
-health status (physical psychosocial)
-plan of care
-recent progress
-any urgent/emergent info
-directives
-vitals, medication list, doses, allergies, diet, activity, equipment/devices, resuscitation status, discharge plan teaching and family’s involvement with care.
Incidents Reports
-key to facility quality and improvement plan
-any accident, unusual event, ex (med errors, falls, missed prescription, needlesticks)
-doc facts not judgment
-do NOT refer an incident repot in a clients medical record
