WEEK 3 Flashcards
Electronic health records (EHR)
A computerized, real-time form of a client’s paper chart that can be shared between members of the interprofessional team; includes information such as the medical history, diagnosis, allergies, and diagnostic testing results.
They are also important for financial reimbursement
Health record
an individualized collection of health information and data about a client’s health
Can clients track their own health using EHR?
yes, like MyChart
What do client’s health records include?
demographics, vital signs, medical history, medications, allergies and immunizations, as well as other information
When did the first utilization of EHRs emerge?
in the 1960s
In what year did the IOM recommend the adoption of EHRs nationwide for safer health care?
1997
What are some advantages of EHRs?
allow providers to follow a client’s care from one facility to another, with information, including a complete medical history, being available instantaneously, enhance communication, medical and prescription errors are reduced, more reliable coding and billing can occur, improve client care and provide for better health outcomes
What are the documentation methods?
Source-oriented medical records
Problem-oriented medical records
Subjective, objective, assessment, and plan charting (SOAP notes)
Problem–intervention–evaluation charting (PIE model)
Focus charting
Charting by exception (CBE)
Source-Oriented Medical Records
traditional format for documenting within a medical record for all disciplines.
It is usually divided into specific sections such as history and physical examination, progress notes, nurses’ notes, laboratory reports, and diagnostic testing.
Why do many institution no longer use the source-oriented medical record?
can limit sharing of information among the members of the interdisciplinary team and lead to fragmented care.
Problem-Oriented Medical Records
Developed by Lawrence L. Weed
Used to create a comprehensive and organized approach among all members of the interdisciplinary team.
What are the four components of the Problem-Oriented Medical Records?
A database in which assessment data are documented
A problem list that lists the client’s problem chronologically
An initial plan that outlines goals, expected outcomes, and further data needed, if necessary
Progress notes using the SOAP (subjective, objective, assessment, plan) format
SOAP documentation
This type of documentation is widely used and allows clinicians to communicate in a systematic and organized way
Component of POMR
SOAP: S
SUBJECTIVE
contains information from the client.
This information can include the client’s feelings or views
collected from the client or sometimes a caregiver or family member
What is an example of S in SOAP?
Client states “I noticed I’m a bit short of breath when I walked in the hallway”
SOAP: O
OBJECTIVE
clinical impressions recorded in this section are based on what the nurse observes or measures
includes: vitals signs and physical assessment findings
What is an example of O in SOAP?
Temperature: 99.4° F (37.4° C); Heart rate 88/min; Respiration rate 20/min; Blood pressure 138/88 mmHg; SpO2 93% on room air while at rest.
Respirations unlabored at rest but becomes slightly dyspneic while speaking. Color is pale. Lung sounds diminished in the bases bilaterally. Frequent cough productive for thick green sputum.
SOAP: A
ASSESSMENT
provided an analysis of the combined subjective AND objective data that were collected
What is an example of A in SOAP?
Client’s respiratory status is altered with productive cough and increase dyspnea
SOAP: P
PLAN
this section details interventions the nurse plans to implement
What is an example of P in SOAP?
Elevate HOB. Notify provider of change in client status. Monitor client’s respiratory status every hour. Encourage coughing and deep breathing. Encourage increased fluid intake.
PIE Model
focuses on the client’s:
Problems
Interventions
Evaluations
Focus Charting
documents a client’s specific health care problem by focusing on the nursing diagnosis as well as changes in the client’s condition, events, and concerns.
The three items that must be documented when using the focused charting method are data, action, and response (DAR).
Charting by Exception
focuses on documenting only unexpected or unusual findings based on standardized protocols.
involves the use of a physical assessment flowsheet with normal or expected findings
Be aware that CBE is not the most effective form of documentation, as it creates the assumption that the client’s care was routine and followed all standards.
What are the advantages of electronic documentation?
Real-time access to client records by all members of the interdisciplinary team
Built-in clinical alerts that contribute to the reduction and prevention of medical errors and duplicate tests
Increased coordination of care
Elimination of illegible records
Client portals that allow the client to interact with providers
FACT Charting
acronym provides a guide for accurate documentation including elements that promote consistency and complete documentation
Factual, Accurate, Complete, and Timely
FACT: F
Factual
should contain concrete, objective, and descriptive information; objective data is obtained by direct observation and measurement: this is what the nurse sees, hears, smells, and feels
What is an example of F in FACT?
Client’s head is round, symmetrical, and normocephalic. No nodules or depressions present when palpated
FACT: A
should establish accuracy by including exact descriptions and measurements.
This provides concrete data for comparing a client’s condition over time.
What is an example of A in FACT?
Client voided 420 mL clear, yellow urine at 0900.
FACT: C
must be complete; it must contain the what, when, where, why, and how. All information provided must be nonbiased.
What is an example of C in FACT?
JR, RN, administered Colace 100 mg PO (by mouth) at 1000. Client denied any discomfort at the time of administration.
FACT: T
documentation should be put in chronological order. This gives a clear understanding of what has happened.
Refrain from charting on clients until the end of the shift.
What is an example of T in FACT?
Blood glucose was obtained at 0732. BS was 127. Per sliding scale, the client received 2 units of Novolog subcutaneously in RUQ of abdomen at 0745. Breakfast tray at bedside
What are some acceptable abbreviations?
ABD
Abdomen
a.c. or ac
Before meals
Ad lib
At liberty (client can move around freely)
BID or b.i.d.
Twice a day
BK
Below the knee
BP
Blood pressure
cath
Catheter
CBC
Complete blood count
c/o
complains of
CPR
Cardiopulmonary resuscitation
C & S
Culture and sensitivity
CXR
Chest x-ray
DNR
Do not resuscitate
DX
Diagnosis
FBS
Fasting blood sugar
GI
Gastrointestinal
gtt
Drop
H&H
Hemoglobin and hematocrit
HOB
Head of bed
hr
Hour
Hx
History
ICU
Intensive care unit
I&O
Input and output
IV
Intravenous
LLE
Left lower extremity
LMP
Last menstrual period
LOC
Level of consciousness
LUE
Left upper extremity
MI
Myocardial infarction (heart attack)
MRSA
Methicillin-resistant Staphylococcus aureus
NG
Nasogastric
NKA
No known allergies
NKDA
No known drug allergies
NPO
Nothing by mouth
N&V, N/V
Nausea and vomiting
O2
Oxygen
OOB
Out of bed
per
Through or by
PO
By mouth
PRN
As needed
q
Every
r/o
Rule out
Rx
Prescription
Stat
At once, immediately
TID
Three times a day
Tx
Treatment
UA
Urinalysis
Wt
Weight
What to do when taking verbal prescription?
write it down in the client’s record as it is received so that is can be read back
The only time a prescription does not need to be written down immediately is when there is an emergency or in a sterile environment. In these situations, the nurse should repeat back the prescription prior to its implementation
When is it acceptable to repeat back a verbal prescription without writing it down first?
in a sterile environment
What prescriptions should you not accept verbal prescriptions?
chemotherapeutic medications,
UNLESS the directive is to withhold or stop the medication.
