Fundamentals of Nursing (Chap 16 Documenting, Reporting, Conferring, and using Informatics)

PIE format-

Problem, Intervention, Evaluation

ISBAR communication-

(communication between members of the healthcare team about a pts condition) *Identify/Introduction- who you are, where you are, why you are communicating *Situation- what is occurring, why the pt is being handed off to another department or unit *Background- what led up to the current situation *Assessment- give your impression of the problem *Recommendation- explain what you would do to correct the problem

SOAP format-

-Subjective data, -Objective data, -Assessment (caregivers judgement about the situation), -Plan (used to organize entries in the progress notes of the POMR)

Why is this entry written incorrectly and is on the "do not use" list of the Joint Commission of Accreditation of Healthcare Organizations (JCAHO)

Epogen 6500 U SQ daily ("U" should not be used, it could be mistaken as a 4, 0, or cc)

ISBARR report to a physician-

I- identify / introduction (name, title, unit) S-situation (give pt name & room #) B-background admission dx, and admission date, medical hx, tx, most recent vs, changes in vs or assessment from prior assessment) A-assessment (your conclusion about the present situation, body system involved, if appropriate, state that the problem could be life threatening) R-recommendation (say what you think would be helpful or what needs to be done, ask about changes in meds) R-read back (restate orders you've been given, clarify how often to do vs, under what circumstances to call back)

Long-Term Care documentation RAI (Resident Assessment Instrument)-

RAI consists of 4 basic components: 1. minimum data set- communication about resident problems and condition 2. triggers- residents who require further evaluation, or who are at risk for developing specific functional problems 3. resident assessment protocols- help identify social, medical, nursing, and psychological problems and form the basis for individualized care planning 4. utilization guidelines- state operation manuals that direct when and how to use the RAI

When recording data regarding the clients health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the care of the client, what style of documentation is the nurse implementing?

SOAP charting

Which of the following clinical situations is addressed by the provisions of HIPPA?

a client has asked his nurse if he can read the documentation that his physician wrote in his chart

Graphic record-

a form used to record specific pt variables such as pulse, respiratory rate, BP readings, body temp, weight fluid I & O's, BM's, and other pt characteristics

Home Health Care documentation OASIS (Outcome and Assessment Information Set)-

a group of data elements that: -represent core items of a comprehensive assessment for an adult home care pt, -form the basis for measuring pt outcomes for purposes of outcome-based quality improvement (OBQI)

According to ANA, Nursing Informatics is-

a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice

Incident report (variance report or occurence report)-

a tool used by healthcare agencies to document the occurrence of anything out of the ordinary that results in or has potential to result in harm to a pt, employee, or visitor

Health information exchange (HIE)-

allows drs, nurses, pharmacists, and other healthcare providers and pts to appropriately access and securely share a pts vital medical info. electronically

Collaborative Pathways-

also called critical pathways or care maps are used in the case management model

Charting by Exception (CBE)-

an abbreviated form of documentation

Besides using the medical records, which form of information should the nurse provide client details to the healthcare team coming on duty in the next shift?

change of shift reports

Occurrence of Variance Charting-

charting the unexpected event, the cause of the event, actions taken in response to the event, and discharge planning when appropriate

Format-

check to make sure you have the correct chart before writing, draw a single line through blank spaces, date and time each entry

The ANA states that the most important purpose for pt records is-

communicating within the health care team and providing info. for other professionals, primarily for individuals and groups involved with accreditation, counseling, legal, regulatory and legislative, reimbursement, research, and quality activities

The patient record-

compilation of a patient's health information

Electronic Health Records (EHR's)-

computer based records where data can be distributed among many caregivers in a standardized format, allowing them to compare and uniformly evaluate pt progress easily

Types of breach-

computers, copiers, cordless & cell phones, fax machines, voice pagers

Documentation guidelines-

content, timing, format, accountability, confidentiality

A client will be transferred from the surgical unit to the rehab unit for further care, what would the nurse expect to include when preparing the verbal handoff report?

current client assessment

Timing-

document in a timely manner. Follow agency policy regarding the frequency of documentation and modify this if changes in the pts status warrant more frequent documentation

Flow Sheets-

documentation tools used to efficiently record routine aspects of nursing care

Content-

enter information in a complete, accurate, concise, current, and factual manner

Change of shift report or handoff-

given by a primary nurse to the nurse replacing him or her or by the charge nurse to the nurse who assumes responsibility for continuing care of the pt

Consultation-

inviting another professional to evaluate the pt and make recommendations to you about the pts tx

A physician suggests that the nurse use the computer terminal that is available at the point of care or at the client's bedside, what is the probable reason for the physicians suggestion?

it keeps the nurse close to the source of data

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes-

limiting abbreviations to those approved for use by the institution (in addition to avoid using abbreviations prohibited by JCAHO)

Progress notes-

notes written to inform caregivers of the process a pt is making toward achieving expected outcomes

Source oriented record-

paper format in which each health care group keeps data on its own separate form

Problem oriented medical record (POMR)-

paper record used in some health agencies. The POMR is organized around a pts problems rather than around sources of information

Personal Health Records (PHR's)-

people who manage their own healthcare online via computer, they include pts medical hx, dx, sx, and medications

Narrative notes-

progress notes written by nurses in a source oriented record

Confidentiality-

pts have a moral and legal right to expect that the information contained in their pt health record will be kept private

Hippa legislation includes-

punishments for anyone caught violating patient privacy. Those who do so for financial gain can be fined as much as $250,000 or go to jail for as long as 10 yrs

Referral-

sending or guiding the pt to another source for assistance

Accountability-

sign your first initial, last name, and title to each entry. don't use dittos, erasures, or correcting fluids,

How can a nurse researcher obtain information from a client record?

study client records

Focus charting-

the purpose of focus charting is to bring the focus of care back to the pt and the pts concerns

Read back-

the recipient reads back the message as he/she heard and interpreted it

Meaningful use-

the use of EHR certified technology to achieve health and efficiency goals

Confer-

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

A nurse caring for a client at a health care facility has to maintain a medical record for the client, what is a use of the medical record?

to investigate the quality of care in the agency

PIE charting-

unique system in that it does not develop a separate plan of care, the plan of care is incorporated into the progress notes which identify problems by number (in the order they are identified)

Discharge summary-

when a pt is discharged from care or transferred from one unit. institution, or agency to another, a discharge summary should be written that concisely summarizes the reason for tx, significant findings, the procedures performed, and tx rendered, the pts condition on discharge or transfer, and any specific pertinent instructions given to the pt and family

The nurse should utilize ISBARR (introduction, situation, background, assessment, recommendation, readback) communication during which following clinical situation?

when communicating a clients change in condition to the physician

Documentation-

written or electronic legal record of all pertinent interactions with the pt (assessing, diagnosing, planning, implementing, evaluating)