Ch. 16 Documentation
Electronic Health Record (EHR)
An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization
A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy?
Calling the client information desk to find out the room number of the family member Getting information from other health care providers violates client privacy. Health care workers must follow the same guidelines to accessing health information on people not assigned to their care. taylor, pg. 341
Home Care Documentation
Documentation of home health care visits that reports the patient's progress serves multiple purposes. Sent to the attending physician with a request for signed medical orders to continue treatment, these records ensure continuity of care. Sent to third-party payers, they establish the need for continuing home care with continued reimbursement for necessary services.
nursing care rounds
Nursing care rounds are procedures in which a group of nurses visit selected patients individually, at each patient's bedside. The primary purposes of nursing care rounds are to gather information to help plan nursing care, to evaluate the nursing care patients have received, and to provide them with an opportunity to discuss their care with those administering it.
What dual purpose does an audit serve?
Quality assurance and reimbursement
Which organization audits charts regularly?
The Joint Commission
case management model
The case management model promotes collaboration, communication, and teamwork among caregivers; makes efficient use of time; and increases quality by focusing care on carefully developed outcomes
progress notes
The purpose of progress notes is to inform caregivers of the progress a patient is making toward achieving expected outcomes.
discharge summary
description of where the patient stands in relation to problems identified in the record at discharge; documents any special teaching or counseling the patient received, including referrals.
source-oriented record
documentation system in which each health care group records data on its own separate form
problem-oriented medical record (POMR)
documentation system organized according to the person's specific health problems; includes database, problem list, plan of care, and progress notes
nursing care plan
includes nursing diagnoses, goals and/or expected outcomes, specific nursing interventions, and a section for evaluation findings so any nurse is able to quickly identify a patient's clinical needs and situation.
consultation
process in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution. The process of inviting another professional to evaluate the patient and make recommendations to you about the patient's treatment.
initial nursing assessment
A typical electronic form used to record the initial database obtained from the nursing history and physical assessment Accurate documentation of these data is important to provide a baseline for later comparisons as the patient's condition changes.
Flow sheets and graphic records
Flow sheets are documentation tools used to efficiently record routine aspects of nursing care (see Fig. 16-5). Well-designed flow sheets enable nurses to quickly document the routine aspects of care that promote patient goal achievement, safety, and well-being.
confer
consult with someone to exchange ideas or to seek information, advice, or instructions. a nurse may consult with another nurse about a particular patient's care.
The nurse is documenting morning care for a client with diabetes. Which documentation is most appropriate for this client?
0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10. Pt is not an appropriate abbreviation for patient and it is understood that all entries are specific to the patient. Avoid the phrases "appears to be" and "seems to be," as they suggest uncertainty. Military time should be used to avoid confusion. Specific, detailed information should be included when possible, such as consumed 80% of breakfast and a reported pain level. Bed in high position is not appropriate for patient safety. Taylor, pg. 342
Focus charting
a documentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care; the focus may be a patient strength or a problem or need; the narrative portion of focus charting uses the data (D), action (A), response (R) format
PIE charting (problem, intervention, evaluation)
documentation system that does not develop a separate care plan; the care plan is incorporated into the progress notes in which problems are identified by number, worked up using the problem (P)-intervention (I)-evaluation (E) format, and evaluated each shift
A new graduate is working at a first job. Which statement is most important for the new nurse to follow?
Use abbreviations approved by the facility. Use abbreviations, but only those that are commonly accepted and approved by the facility. Taylor, pg. 345
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. While the nurse can see what has not been done, it is not the main reason for bedside reporting. A clean room is not a part of bedside reporting. Bedside reporting should be client-focused, not nurse-focused. Taylor, pg. 361
The nurse is caring for a client admitted with acute pancreatitis. The client is nauseated and receiving IV fluids at 125 mL/hr, The client is NPO and has received morphine sulfate 4 mg IV for pain with a decrease of epigastrc pain of a 4/10 on the pain scale. Because the facility charts by exception, which progress note represents this method?
4/10 pain on pain scale, epigastric pain; with reports of nausea Charting by exception charts only that which falls outside the standard of care and norms. 125 mL/h of normal saline, NPO, pain 4/10 on pain scale with 4 mg IV morphine every 4 hours - this documentation is incorrect because the IV fluids and morphine are expected to occur. NPO, 4/10 pain, epigastric pain, nausea is incorrect because NPO is expected. 4/10 pain with nausea; on IV fluids is incorrect because IV fluids are expected.
Purposes of Patient Records
Communication with other healthcare professionals Record of diagnostic and therapeutic orders Care planning Quality of care reviewing Research Decision analysis Education Legal and historical documentation Reimbursement
nursing informatics and its contributions to health care
Increases in the accuracy and completeness of nursing documentation Improvement in the nurse's workflow and an elimination of redundant documentation Automation of the collection and reuse of nursing data Facilitation of the analysis of clinical data
Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation?
It provides quick access to abnormal findings. Charting by exception (CBE) provides quick access to abnormal findings as it does not describe normal and routine information. When using the PIE charting method, assessments are documented on separate forms. The PIE charting method, not charting by exception, records progress under problems, intervention, and evaluation. The client's problems are given a corresponding number in the PIE charting method, which is used in the progress notes when referring to interventions and the client's responses. Taylor, pg. 355
The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records?
Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. Emphasizing goal-directed care to promote the recording of pertinent data that will facilitate communication among healthcare providers is an advantage of problem-oriented recording and is therefore correct. Giving the clients the right to withhold the release of their information to anyone is beneficial disclosure, and is not an advantage for problem-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 are examples of source-oriented recording. Taylor, pg. 353
critical/collaborative pathways
The case management plan is a detailed, standardized plan of care that is developed for a patient population with a designated diagnosis or procedure. It includes expected outcomes, a list of interventions to be performed, and the sequence and timing of those interventions
A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements?
a client who is homebound and needs skilled nursing care Home care Medicare reimbursement requirements would necessitate the client meet the following qualifications: the client is homebound and still needs skilled nursing care, rehabilitation potential is good (or the client is dying), the client's status is not stabilized, and the client is making progress in expected outcomes of care. Taylor, pg. 358
A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?
identifying risks and ensuring future safety for clients Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action, and they are not commonly used to communicate within the interdisciplinary team. Taylor, pg. 362
Charting by exception (CBE)
is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes.
