Unit 3 Fundamentals Documenting, Reporting, ....
What is a change of shift report?
Given by the 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 patient
What is the patient record?
a compilation of patients health information
What is a graphic sheet?
a form used to record specific patient variables such as pulse, respiratory rate, blood pressure, temperature, weight, fluid intake and output, bowel movement
What is a nursing care conference?
a meeting of nurses to discuss some aspects of a pts care
What are personal health records?
a record that patients are keeping with their past diagnosis, symptoms, and medications and other medical info
What is a Kardex?
care plan put on a folded card for each patient
What is source-oriented records?
one in which each healthcare group keeps data on its own separate form
What is problem-orientated medical records (POMR)?
organized around a patients problems rather than around sources of information
What should a nurse do when their patient is being transferred somewhere else?
report a summary of the pts condition and care
What is the only permanent legal document that details the nurse's interaction with the patient?
the patients record
What is a consultation?
the process of inviting another professional to evaluate the patient and make recommendations to you about his or her treatment
What is a referral?
the process of sending or guiding the patient to another source for assistance
What is documentation?
the written or typed legal record of all pertinent interactions with a patient - assessing, diagnosing, planning, implementing, and evaluating
What is the purpose focus charting?
to bring the focus of care back to the patient and the patients concerns
What is SOAP used for?
to organize data entries in the progress notes of the POMR
What is nursing care rounds?
where a group of nurses visit selected patients individually at each pts bedside
What does it mean to confer?
consult with someone to exchange ideas or to seek information, advice, or instructions
What is the case management plan?
critical/collaborative pathways that is a detailed standardized plan of care that is developed for a patient population with a designated diagnosis or procedure
What is a benefit to electronic medical records?
data can be distributed among many caregivers n a standardized format allowing then to compare and uniformly evaluate patient progress easily
What are flow sheets?
documentation tools used to record routine aspects of nursing care
What is minimum data sets?
facilitates data and outcome comparison; this info will use uniform definitions to create a common language among multiple healthcare data users
What is progress notes?
notes written to inform caregivers of the progress a patient is making toward achieving expected outcomes
What is some info that is exchanged between nurses on the change of shift report?
- basic identifying info about each patient - name diagnosis, room # - current appraisal of each patient such as changes in status, pertinent monitoring data, abnormal findings in assessment, pain level - Current orders - upcoming or ongoing test - Abnormal occurrences during your shift - any unfilled orders - reports on pt that has be discharged or transferred
What should you do when giving a telephone or telemedicine report?
- Identify yourself and the patient and your relationship to the pt - report concisely and accurately the change in the pt condition - report pt current vital signs and clinical manifestation - Have pts record at hand to make knowledgeable responses to physician inquiries - concisely record the time and date of call, what was communicated and the physicians response
What does SOAP stand for?
- Subjective Data - Objective Data - Assessment - Plan
What types of forms are used in source-oriented patient records?
- admission sheets - admission nursing assessment - graphic sheet - flow sheet to record routine care - narrative nurse notes - medication sheet - medical history and examination sheet - physicians order sheet - physicians progress notes - misc. forms such as lab reports, x-rays, consultations, dietary, types of therapy
What does the case management model promote?
- collaboration - communication - teamwork - makes efficient use of time - increases quality by focusing care on carefully developed outcomes
What are the purposes of patients records?
- communication - diagnostic and therapeutic orders - care planning - quality review - research - decision analysis - education - legal documentation - reimbursement - historical documentation
What are the characteristics of effective documentation?
- consistent w/ professional and agency standards - complete - accurate - concise - factual - organized and timely - legally prudent - confidential
What is advantage of charting by exception?
- decreased charting time - a greater emphasis on significant data - easy retrieval of significant data - timely bedside charting - standardized assessment - greater interdisciplinary communication - better tracking of patients responses - lower cost
What are the 3 methods of communication for nurses?
- documentation - reporting - conferring
What are some common methods of communication among healthcare professionals?
- face to face - telephone conversation - written message - audio taped message - computer message
What is the primary purpose of nursing care rounds?
- gather info to help plan nursing care - evaluate the nursing care the pts has received - to provide the pt with an opportunity to discuss his or her care with who is administering it
Way to breach patient confidentiality?
- giving pt info over the phone to alleged spouse - talking about pt in the elevator - giving info about pt to someone that is not involved in pt care - discussing pt info in a public place - leaving pt info in public area - leaving computer unattended - failing to log off of computer - sharing or exposing passwords - copying or providing data - Improperly accessing, reviewing, or releasing pt info
What are the formats for nursing documentation?
- initial nursing assessment - Kardex and patient care summary - plan of nursing care - critical/collaborative pathways - progress notes - flow sheets - discharge and transfer summary - home healthcare documentation - long term care documentation
What are the four basic components of RAI?
- minimum data set: communication about residents problems and conditions - triggers - resident assessment protocols: help form basis for individualized care plans - utilization guidelines
What are guidelines for safe computer charting?
- never give passwords out - never leave computer unattended - follow correct protocol for correcting errors - never create change or delete records unless you have authority to do so - make sure there are back up files - dont leave info displayed
What three categories are minimum data sets organized into?
- nursing care elements: diagnosis and interventions - pt demographic elements: sex, date of birth - service elements: admission and discharge dates
What are the benefits to RAI?
- residents respond to individualized care - staff communication becomes more effective - resident and family involvement increase - documentation becomes clearer
According to HIPPA patients have the right to what?
- see and copy their health record - update their health record - get a list of the disclosures a healthcare institution has made independent of disclosures made for purposes of treatment, payment, and healthcare operations - request a restriction on certain uses or disclosures - Choose how to receive health information
What are the different methods of documentation?
- source-oriented records - problem-oriented records - PIE - problems, intervention, evaluation - focus charting - charting by exception - case management model - computerized documentation and electronic medical records - Personal health records
What are the medicare requirements for home healthcare?
- the pt is homebound and still needs skilled nursing care - rehabilitation potential is good or the pt is dying - pts status is not stabilized - pt is making progress in expected outcomes of care
What are the different diagnostic and therapeutic orders?
- verbal - telephone - fax
What is the narrative portion of focus charting?
Data Action Response
What is one advantage of PIE?
It promotes continuity of care
What is a SBAR?
It stands for Situation, Background, Assessment, Recommendation and it is a technique that is the framework for communication between members of the healthcare team about a patients condition
What does PIE stand for?
Problem Intervention Evaluation
What is documentation in long term care specified by?
RAI Resident assessment instrument
What is charting by exception (CBE)?
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
What is nursing informatics?
a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice
What is a discharge summary?
a summary of reason for treatment, significant findings, procedures performed, treatments rendered, pts condition on discharge, and other pertinent instructions
What is PIE Charting?
a system that is unique in that it does not develop a separate plan of care. The plan of care is incorporated into the progress notes in which problems are identified
What is the advantage of a POMR?
all healthcare professional record pt info on the same thing and then they work together to figure out the list of the patients problems and they all contribute to the plan of care
What are collaborative pathways?
also called critical pathways or care maps; used in the case management model that specifies the plan of care linked to expected outcomes along a timeline
What is an incident report?
also called variance or occurence report, is a tool used by healthcare agencies to document the occurrence of anything out of the ordinary that results in or has the potential to result in harm to a pt, employee, or visitor
In reporting to family members or significant others what should the nurse always do?
always clarify with the pt who is entitled to progress reports and if the pt is not able to communicate in an emergency situation the nurse should always use their best professional judgement
What is the advantage of focus charting?
holistic emphasis on the patient and the patients priorities
What are progress notes?
inform caregiver of the progress a patient is making toward achieving expected outcomes
What is variance charting?
it is used when a pt fails to meet expected outcomes or a planned intervention is not implemented
What is a limitation to case management models?
it works best on typical patients with few individualized needs
What is a major drawback on charting by exception?
limited usefulness when trying to prove high quality of safe care in response to a negligence claim made against nursing
What is narrative notes?
progress notes written by nurses in a source-oriented record that addresses routine care normal findings, and patient problems identified in the plan of care