Ch. 10: Documentation, EHR, and reporting (Yoost)

What should a care plan include?

Patient preferences, and goals developed by patient and nurse

Documentation is usually organized in the following way for S O APIER note

S: What's your patience and others tell you O: what are the result of physical examination, relevant, vital signs or other test? A: What is the patient's current status? P: What interventions are necessary? I: What treatment did the nurse provide? E: What are the patient outcomes after each intervention? R: Does the plaN stay the same? what changes are needed to the care plan

SOAP note

S: subjective O: objective A: assessment P: plan

SOAPIE notes

S: subjective O: objective A: assessment P: plan I: Actual Interventions E: Evaluation of intervention Outcomes

Identify the standards for affective documentation by nurses

Standards for documentation should be in the agreement with TJC standards, the general principles of medical record and documentation from the center of Medicare and Medicaid services in the ANA standards

Here playing should clearly identify patients preferences, with goals mutually developed by patient and nurse. True or false

TRUE

Confidentiality

being entrusted with private patient information. Patient information must be safeguarded and the information only shared with individuals who have a need and a right to know. Nurses have a legal and professional obligation to protect patient information. I like the part of the attic standard of professional performance, the nurse protect patient information within the ethical and legal perimeters of nursing practice

Narrative charting

chronologic, with a baseline recorded on a shift-by-shift basis

Documentation is a way of demonstrating :

demonstrating the professional and legal standards of care that are met and is sometimes used to determine reimbursement of care

Charting by exception

documentation that records only abnormal or significant data

admission summary

includes the patient's history, a medication reconciliation, and an initial assessment that addresses the patient's problems, including identification of needs pertinent to discharge planning and formulation of a plan of care based on those needs.

problem-oriented medical record (POMR)

integrates charting from the entire care team in the same section of the record Formats such as PIE, APIE, SOAP, SOAPIE, SOAPIER, DAR, or CBE format

Expected nursing documentation includes a nursing assessment, the care plan,_____________, the patient outcomes or responsive care, and the assessment of patient ability to manage after discharge,

interventions

Verbal/telephone orders

limited to emergency situations at many facilities. Must be taken by a registered nurse (RN), who repeats the order verbatim to confirm accuracy and then enters the order into the EMR. documents it as a verbal or phone order and including the date, time, physicians' name, and RNs signature. Most facilities require the physician to co-sign a verbal or telephone order within a defined period.

If an error is made on electronic documentation, it can be corrected on screen view or as an addendum depending on the EHR program used , but the erroro or correction process will

remain in the permanent electronic record

SBAR communication

(Situation, Background, Assessment, Recommendation) - framework for communication between members of the healthcare team about a patient's condition. Use for nurse and physician interactions. Situation : What is happening at the current time? Background: What are the circumstances leading up to this situation Assessment: What does the nurse think the problem is ? Recommendation: What should we do to correct the problem?

1. Same as electronic medical record ? 2. Electronic Health Record (EHR)?

1. Is a record of one episode of care such as an inpatient stay or an outpatient appointment 2. a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting

American Recovery and Reinvestment Act (ARRA) 2009 act Mandate what?

The government mandated the use of certified EHR for every person in the United States by 2014

SOAPIER note

A format for documentation stands for Subjective data, Objective Data, Assessment, Plan, Intervention, Evaluation, Revisions to Plan.

What is done when a error is made on a paper documentation?

A line is drawn over the error and the word error is written, after the entry, along with the nurse's initial followed by correct entry

Medication Administration Record (MAR)

A list of ordered medications, along with dosages and times of administration, on which the nurse initials medications given or not given.

Effective use of technology in standardized best practice Patel facilitated by the EHR enables

The nurse to provide safe for patient care

DRGs (diagnosis-related groups)

Accurate documentation is necessary for hospitals to be reimbursed by Medicare or Medicaid according to these groups. Each DRG is reimbursed at a specific rate based on the average use of resources to treat specific DRG. Payment is often based on documentation supporting to print the patient received her in the hospital stay

Nursing documentation demonstrates nursing contribution to patient care and must be

Accurate, timely, comprehensive, and relevant

CPOE (Computerized Physician Order Entry)

Application used by physicians and other health care providers to enter patient care information. Also provides support tools that result in improved care and patient outcomes.

APIE notes

Assessment Problem Intervention Evaluation (combine subjective and objective data with the pie format) A: Patient holding hand over surgical site and grimacing with report pain at level 8/ 10 on a pain scale

DAR note

D-data A-action R-response Used to chart the data collected about the patient's problems, the action initiated, and the patient's response to action. EX: : D: patient grimacing. Holding Hand at abdominal surgical site. Pulse 98 dot states pain at level 8/10 A: given morphine sulfate 5 mg IV per order and reposition for comfort R: 20 minutes after morphine is given patient states relief with a pain level at 3/10.

point of care documentation (POC)

Documentation that takes place as care occurs computers are in each patient's room, what will devices such as tablets, or workstation on wheels can be moved in and out the patient's bedside. This is to promote timeless goals and accuracy of documentation

Flow Sheets

Flowsheets and checkless within the EHR maybe used to document routine and care observations that are recorded on a regular basis : ex. vital signs, medications, and intake output measurements.

Patient participation and handoff reports

Handoff reports are enhance with patient participation nurses should: - teach patients to actively participate with staff during bedside - ask patience to validate the information shared during round processes - encourage patient to ask questions during rounding process

The major components of EHR are:

Health information, diagnostic test results, and orderly entry system, and decision support. Health information can private comprises compromise patient data such as democratic assessment findings flowsheets that include point of care results diagnosis nursing treatments and medication profile listing historical , currently active medication orders.

ISBAR

I: Identify (yourself) S: Situation (current) B: Background (before) A: Assessment (problem) R: Recommendation (what should be done?)

what is one disadvantage of the EHR system

Is that there are many different software's and web-based systems - each with their own unique characteristics.

Are what are the functions of the medical record including the electronic health

It is an accurate comprehensive record of a patient health care encounter in a major communication tool between the healthcare providers

bar-coded medication administration (BCMA)

Medication administration. The use of a portable scanner, the nurse scans the patient's wristband and the medication to be given.

Do not use abbreviations

Nurses must be aware of the danger of using abbreviations that may be misunderstood and compromise patient safety Document using only accepted abbreviations and acronyms to facilitate effective communication among care providers that supports safe patient care

Explain the process of accepting verbal and telephone orders

Only RNs can accept verbal or telephone orders, and they must immediately enter the order into the EHR

hand-off report

The real-time process of passing patient-specific information from one caregiver to another or among interdisciplinary team members to ensure continuity of care and patient safety. -Can be oral, as in a face-to-face meeting or telephone communication, or they can be written, recorded, or printed from the EHR.

written medical records

The use of paper medical records requires no special technical training. Play paper records are now rarely used except in case of electronic system downtime due to power outages or mass disaster. When using paper documentation, nurses are responsible for knowing how to correctly spell and document events

PIE notes

Used to document problem P-problem I-intervention E-evaluation Example note - P: acute pain lower right quadrant of abdomen rated by post surgical patient at 8 out of 10 I: Morphine sulfate (5 mg IV ) given at 0930 per order for lower quadrant abdominal pain relief E: patient reports a 3/10 pain level 20 minutes after morphine was admitted

Medical record increase cannot be altered or obliterated in the EHR if information is corrected in the EHR, the new information is

Visible on the screen view but the correction process is still part of the permanent medical record

-Assessment -Diagnosis -Planning -Implementation -Evaluation

What are the five aspects of nursing process?

-Date -Time -Signature with credentials of person documenting Usually occurs automatically

What are the requirements for documentation?

Incident reports

When an unusual and unexpected event involving a patient, visitor, or staff member occurs, an incident report is completed. Examples: fall, medication error, equipment malfunction Factual only, objective, nonjudgmental The purpose of this report is to document the details of the incident immediately to ensure accuracy. Not part of the medical record

Medical Record

a document with comprehensive information about a patient's health care encounter, as well as demographic, administrative, and clinical data

Electronic Medical Record (EMR)

a record of one episode of care, such as an inpatient stay or an outpatient appointment

Sentinel event

a safety occurrence that affects a patient and causes death, serious permanent or temporary injury, or requires interventions to sustain life. Medication errors, falls, and delay in treatment-could occur due to incomplete hand-off reporting. 2005 70% of sentinel events were caused by communication breakdowns and 50% of those occur during patient handoff

discharge summary

addresses the patient's hospital course and plans for follow-up, and it documents the patient's status at discharge.

Computerized provider order entry (CPOE)

allows clinicians to enter orders in a computer that are sent directly to the appropriate department The electronic record provide connectivity to enhance communication between all members of healthcare teams, we can access an update the records the mistake simulataneously.

Health Care Documentation

any written or electronically generated information about a patient that describes the patient, the patient's health, and the care and services provided, including the dates of care.

Documentation should be :

factual, accurate, and nonjudgmental, with proper spelling and grammar. Events should be reported in order they happen and document it should occur as soon as possible after assessment, intervention, condition change, or evaluation.

Case management documentation

focused on providing and documenting high-quality, cost-effective delivery of patient care.. Goal: is to achieve realistic and desired patient and family outcomes within appropriate lengths of stay and with appropriate use of resources.

Handoffs provide accurate and timely information about the care, treatment, and services rendered to a patient, addressing the patient's current condition and anticipated changes.

handoffs

Nursing documentation should clearly describe the patient's ?

health status and include a care plan that reflects the need and gold of the patient, with each step of the nursing process documented, along with the changes to the plan of care

Health Insurance Portability and Accountability Act (HIPAA)

originally passed in 1996, created standards for the protection of personal health information, whether conveyed orally or recorded in any form or medium. The act clearly mandated that protected health information may be used only for treatment, payment, or health care operations.

formatted charting

problem-oriented documentation, can be completed in a variety of formats and follows a selected structure.

Diagnosis findings include current and historical results for procedures, laboratory test, and x-rays. Threw a fart

true

Medical record documentation should be based on facts not opinions true or false

true