CHAPTER 16 Documenting, Reporting, Conferring, and Using Informatics

Incident report

An incident report, also termed a variance report or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in (or has the potential to result in) harm to a client, employee, or visitor. These reports are used for quality improvement and not for disciplinary action. They are a means of identifying risks and high-risk patterns as well as initiating in-service programs to prevent future problems.

CONFIDENTIALITY

Any information that can identify a person is considered confidential. A medical condition may identify a client who was cared for, especially if the location of the clinical site and unit was disclosed in the post. Discussion of clinical experience can be used for teaching purposes or seeking advice on care. No care should be discussed, even privately, with friends and family.

PIE charting method

Assessments are documented on separate forms. records progress under problems, intervention, and evaluation. The client's problems are given a corresponding number

Place the steps in order for developing a nursing plan of care.

Defining Characteristics and establishing a Nursing Diagnosis Patient Goal Patient Outcomes and Criteria Interventions Rationale Evaluation EXPLANATION: A step-by-step process is evidenced by: Sufficient data are collected to substantiate nursing diagnoses. At least one goal must be stated for each nursing diagnosis. Outcome criteria must be identified for each goal. Nursing interventions must be specifically designed to meet the identified goal. Each intervention should be supported by a scientific rationale. Evaluation must address whether each goal was completely met, partially met, or completely unmet.

Source-oriented recording.

Demonstrating a unified approach for resolving the clients' problem among caregivers and having numerous locations for information where each member of the multidisciplinary team makes entries about their own specific activities in relation to the client's care

Problem-oriented recording

Emphasizing goal-directed care to promote the recording of pertinent data that will facilitate communication among healthcare providers

The Health Insurance Portability and Accountability Act (HIPAA)

Gives clients the right to see their own medical records, and they can also obtain a copy of it. Therefore, clients reserve the right to request changes in accurate information. The other responses are inaccurate.

beneficial disclosure

Giving the clients the right to withhold the release of their information to anyone

Referral.

Referring is the process of sending or guiding the client to another source for assistance.

The Joint Commission

The Joint Commission audits client records regularly and encourages institutions to set up ongoing quality assurance programs.

What is the primary purpose of the client record?

The primary purpose of the client record is to help health care professionals from different disciplines communicate with one another.

Data base

contains initial health information about the client.

Progress notes

describe the client's responses to what has been done and revisions to the initial plan.

Plan of care

identifies methods for solving each identified health problem.

Conferring

is to consult with someone to exchange ideas or seek information, advice, or instructions

An occurrence report

should be completed when a planned intervention is not implemented as ordered.

Verbal orders

should only be accepted during an emergency.

A flow sheet

Is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics.

Acuity charting forms

allow nurses to rank clients as high to low acuity in relation to the client's condition and need for nursing assistance or intervention.

Problem list

consists of a numeric list of the client's health problems

Charting by exception (CBE)

provides quick access to abnormal findings as it does not describe normal and routine information.

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate?

"It will allow for us to see the client and possibly increase client participation in care." Beside reports are done to increase client safety and stimulate participation in care. it is not the main reason for bedside reporting. Bedside reporting should be client-focused.

In SOAP charting

SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. everyone involved in a client's care makes entries in the same location in the chart.

Consultation

is the process of inviting another professional to evaluate the client and make recommendations about treatment.

What situation would permit the nurse to disclose information without the client's approval?

Reporting abuse and neglect is mandatory according to the state law and is therefore correct.

The nursing is caring for a client who requests to see a copy of his health care records. What action by the nurse is most appropriate?

The nurse needs to be aware of the policies regarding clients reviewing health care records. Teaching the client how to navigate the health care records is not appropriate. Hospitals can be fined for not allowing clients to view their health care records. There is no regulation requiring the clients to view a paper copy of the records.