Documentation of care notes

What is HIPPA

Health insurance portability and accountability act

What are accountability things to consider while charting?

Sign first initial, last name and title to all entries. Do not sign your name to anything that is not true. Never use erasers or correcting fluid. Draw a single line through an error and write "mistaken entry" or "error in charting" above it. Identify each page of the medical record with pt name and ID number. Remember that every portion of the medical record is permenant.

What is SBAR?

Situation Background Assessment Recommendation

Describe methods of documentation

Source oriented records Problem oriented medical records (soap)

What is documentation?

Written or typed legal record of all pertinent interactions with a patient

What is important to remember about confidentiality

All pt information is confidential. Includes written, computerized or spoken. Never share any pt information or experiences on a social network. Access to pt information only on an "AS NEEDED TO KNOW" basis. Direct caregivers. Know your agency's policy regarding pt records.

What are minimum data sets?

Are categories that uniformly measure the outcomes of healthcare facilities and are published as a type of "report card" for consumers searching for healthcare Used in medicare and medicaid long term care facilities

Describe problem oriented medical records

Arranged according to client problems Includes database, problem list, plan of care & progress notes Uses SOAP format in the progress or narrative notes Advantages: Encourages collaboration & problem list at front of chart makes tracking easier Disadvantages: Not all providers familiar with charting format Extra work to maintain problem list

The nurse is preparing to turn a client care over to the next shift. The client asks the nurse to wait in the room because the client is alone until the next nurse arrives. The best response by the nurse to the client is: A. You will be fine for a half hour B. I need to tell the new nurse how you are progressing with care C. You do not need a nurse in the room all the time D. Ill find your spouse to sit with you

B.

A client has specific cultural needs with regard to the plan of care. In a POMR this information would be found in which of the following? A. Database B. Problem list C. Plan of care D. Progress notes

B. Problem list

PIE notes, SOAP notes, focus charting and CBE are examples of which of the following formats for nursing documentation? A. Critical/collaborative pathways B. Progress notes C. Flow sheets D. Discharge summary

B. Progress notes

The nurse charts in the narrative progress notes of a client record. The nurse includes statements by the client, direct observations, conclusions drawn from the data, and the plan of care. What is the acronym for this style of charting? A. DAR B. SOAP C. SBAR D. NANDA

B. SOAP

Which of the following methods of documentation is unique in that it does not develop a separate plan of care but instead incorporates the plan of care into the progress notes? A. Source oriented records B. Problem oriented records C. PIE D. Focus charting

C. PIE

When to use SBAR?

Change of shift reports Telephone reports Transfer and discharge reports Reports to family members Incident reports

Describe the purpose of pt records.

Communication Diagnostic & therapeutic orders Care planning Quality review Research Decision analysis Education Legal documentation Reimbursement Historical documentation

What is DAR

DATA: assessment & nursing observations ACTION: planning and interventions RESPONSE: evaluations of interventions

Describe Disadvantages of PIE

Difficult to track current problems and effective interventions

Describe source oriented records

Divided into departmental sections Uses progress notes Benefits: Easy for providers to know where to chart Easy to read information specific to dicipline Disadvantages: Client problems scattered throughout the chart Can decrease communication between providers

Describe Charting by Exception (CBE)

Documentation system that uses narrative notes only for abnormal or significant findings Uses flow sheets annd graphic charts for most assessments Agency based standards printed on flow sheets to reflect normal findings

What is EMR?

Electronic medical record

What is focus charting?

Focuses on clients concerns and strengths Uses progress notes organized into DAR Provides a holistic perspective of client Uses flow sheets and checklists for routine assessments & interventions

What if something doesn't get documented?

It is as if it never happened.

Describe PIE

It uses assessment flow sheets and progress notes

What are some documentation guidelines

Keep it complete, professional, accurate, concise, current and factual. Make sure it reflects the nursing process. Avoid words like good, average, normal or sufficient. Avoid generalizations. Document problems as they occur. Chart precautions or preventative measures used. Document medical visits and consults that impact pt care. Document in a legally prudent manner.

Describe documentation guidelines when it comes to timing of documentation

Most agencies want it at "point of care" never leave the unit when a pt is critically ill unless your documentation is up to date. Indicate the date and time of entry. Specify the date and time of occurrence. Most organizations use military time. Only document what you have actually done

Describe advantages of PIE

No care plan needed Promotes continuity of care

What is PIE?

Problems Interventions Evaluation

Hippa guidelines state pt's have the right to:

See and copy their health record. Update their health record. Get a list of a healthcare facility has made other than for purposes of treatment, payment or healthcare operations. Request a restriction. Request a restriction on certain uses or disclosures. Choose how to receive health information.

What is SOAP?

Subjective data: What the client says Objective: Information you observe through the senses Assessment: Interpretation or conclusions drawn about subjective and objective data Plan: plan of care designed to resolve the problem

Who are documentation standards established by?

The ANA, Centers for medicare and medical services CMS, and accrediting organizations

True or false One of the purposes of creating a pt record is to evaluate the quality of care patients have received and the competence of the nurses providing that care.

True

True or false. A nurse who fails to log off a computer after documenting pt care has breached pt confidentiality

True

When do you write a progress note?

Upon admission, transfer to another unit and discharge. When a procedure is performed. When a pt arrives from surgery. When calling an MD regarding critical pt information. For any change in pt status.