Documentation

What are the some things documentation must be able to do?

1. Accurate 2. Comprehensive 3. flexible for Critical Date(Emergency) 4. Research and outcomes 5. maintenance of care 6. reflect current practices of nursing 7. demonstrte quality of care 8. meet standards and legality 9. minimize errors 10. HIPPA 11. save time

What are the 4 types of Reports?

1. Change of Shift 2. Telephone/ Verbal Orders/ Reports(Must be verified by physician within 24 hours) 3. Transfer records 4. Incident Records

What is the purpose of documentation

1. Communication(doctor, labs, nurses, pharm) 2. Legal document 3. billing 4. education 5. Research 6. Auditing and monitoring

What are some methods of Documentation

1. Narrative(blank paper writing) 2. Problem Oriented(Most used find out prob and fix) 3. Source Records(traditional) 4. Charting by exception(when WNL) 5. Case Management/Critical Pathways(Collaborative)

Documentation DO's

1. Sign your name and follow with title 2. black ink for all writing 3. forms have patients label 4. only use hospital approved abbreviations 5. keep record of physicians calls and recommendations 6. write neatly 7. Use military time 8. document in timely manner 9. note "late entry" if out of time zone 10. draw single line through error and initial and date 11. include all patient education

What is documentation

1. any written or electronic info that describes the patient care delivered and response to that care 2. the quality of doc reflects your nursing quality

Documentation DONT'S

1. chart your personal opinions 2. falsify record 3. chart in advance 4. leave blanks 5. erase or use white out 6. use general words like appear 7. assume about an accident..only use facts 8. incident report in chart

How do you fax patient info?

1. confirm fax # 2. include cover sheet 3. programmed speed dial 4. machine in secure area/ 5. limit usage

What is Charting by Exception? Disadvantages?

1. documents normal findings and routine care on clearly defined standards 2. documents deviations from normal 3. Uses flow sheets, standards, reduces multiple charting and time. Can pose legal threat if not documenting exceptions

What are advantages to nursing information systems?

1. increased time with patients 2. access to info 3.quality of doc 4. reduced errors 5. reduced hospital cost 6. nurse job satisfaction 7. compliance with TJC 8. develops common clinical database

What are advantage to Electronic Medical Record?

1. provide real time relaible acces to client info 2. captures episodic and longitudinal info 3. Uses EBC 4. data used for QI 5. Data for reimbursement 6. support clinical research, public health & reporting

What are the Documentation forms

Admission(History & Assessment) Flow Sheet/ Graphic Sheet(Vital Signs & Routine Care) Kardex(record of current orders) Acuity Records(how much care needed) Care Plans Discharge Summary Forms(Walker, assisted living)

What do Clinical Information Systems include?

CPOE Nursing Laboratory Pharmacy Radiology

How do you dispose of patients printed health record?

Dispose in locked shredding box

What are two examples of electronic medical record?

EPIC & NEEHR Perfect

What are desired qualities of documentation

F actual A ccurate C omplete C urrent O rganized

What is POMR charting? Disadvantages?

Focuses on patient problems Nursing Care Plans Progress Notes SOAP PIE DAR New for a lot of old nurses

What is the main advantage of CPOE

Medical errors are reduced because manual transcriptions are eliminated.

What is SBAR

S ituation B ackground A ssessment R ecommendation Use to communicate with physician, respiratory when problem arises in patient (Ex. Short of breath, history of lung cancer, Resp 24, Breathing Treatment)

What is Narrative charting? Disadvantages?

Story like, traditional Repetitious and time consuming

What characteristics need to be used in reported patient information verbally?

T imely A ccurate R elevant O rganized

What is Source Record Charting? Disadvantages?

Traditional charting format, separate section for each discipline Details about problem are all over chart

What are some challanges to nursing information systems?

confidentiality security passwords

What is Case Management/ Critical Pathways? Disadvantages?

multidisciplinary care plans, collaborative, outcome focused May not be individualized