TLO 4.1a Documentation Flashcards
Healthcare members use health records to?
Communicate Legal documentation of care provided Continuity of care Quality improvement Reimbursement
Why computer charting?
Keeps all records in one place
Decreases incidences of lost information
Enhances communications
Electronic Health Record (EHR): all inclusive of all visits (lifelong)
Electronic Medical Record (EMR): legal record that describes a single encounter or visit
Computer charting objectives?
Provide a lifetime patient record
includes problem list
Supports direct entry of patient data by physician
Support confidentially
Provide continuous access to multiple users at same time
Measures costs and quality of care
Flexible and expandable to meet needs of organization
Electronic Health Record
Contains?
Benefits?
Computerized health record
Contain interdisciplinary notes, labs, clinical documentation, diagnoses, etc.
Benefits: improved access to information can be accessed remotely info stored and retrieved quickly nurses spend 25% less time documenting aggregated data reports can be generated quickly
When/What to document?
Begins at the beginning of shift initial assessment
Chart as soon as possible after you give care or make an observation
Chronologically to communicate change in status or interventions, teaching, consents, contacting provider, AMA etc
Never chart ahead
you will sign your name electronically or written:
ex: J. Trethewey SN, MCC
Legal guidelines for documentation?
Use black ink
Write legibly/type if EHR
Do not leave blanks lines in narrative notes, draw line after
Use only agency approved abbreviations
Maintain confidentiality
Sign all charting with name and credentials
No scratch outs or erasures
No biased statements, just the facts
Chart for yourself do your own assessments
Chart actual time
Legal guidelines: Malpractice?
Failure to record: pertinent health or drug information nursing actions medication administration drug reaction or change in patient condition
Incomplete or illegible records
Failure to document discontinued medications
Documentation formats?
SOAPIE
PIE
DAR
What is SOAPIE?
Subjective Objective Assessment Plan Intervention Evaluation
What is PIE?
Problem
Intervention
Evaluation
What is DAR?
Data
Action
Response
Charting by Exception?
Patient meets all standards, unless otherwise documented “within defined limits” (WDL)
EPIC
Uses flow sheets
Emphasis on abnormal findings
Charting by exception
ADVANTAGES?
DISADVANTAGES?
Advantage:
reduces documentation time
eliminates redundancy documents abnormal findings
Disadvantage:
omissions of main pt problem r/t disagreement on problem or variation
Change of shift reporting may be given?
Orally
Taped
Face to face
Bedside report
Change in shift reports include?
Name, age, room number Allergies, code status Admit reason Pertinent medical history Abnormal assessment finding in each body system Pain and pain medications Diet, how tolerated, blood glucose IV sites IV meds and rates Ambulation, fall risk Height/weight
