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Thread: Documentation

  1. #1
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    Default Documentation



    Documentation


    Question Answer
    chart (health care record) legal record used to meet the demands of the health, accreditation, medical insurance, and legal systems
    charting, recording, or documenting the process of adding written information to the chart
    auditors people appointed to examine patients' charts and health records to assess quality of care
    peer review an appraisal by professional co-workers of equal status
    quality assurance/assessment/improvements an audit in health care that evaluates services provided and the results achieved compared with accepted standards
    diagnosis related groups (DRGs) a system that classifies patients by age, diagnosis, and surgical procedure
    nursing notes the form on the patient's chart on which nurses record their observations, care given, and the patient's responses
    traditional (block) chart a chart divided into specific sections or blocks; emphasis placed on specific sheets of information
    narrative charting recording of patient care in descriptive form
    problem-oriented medical record (POMR) based on the scientific problem solving system or method; principle sections are database, problem list, care plan, and progress notes
    database the accumulated data from the history, physical exam, and diagnostic tests used to identify and prioritize the health problems on the master medical and other problems list
    problem list prioritized master list of the patient's active, inactive, temporary, and at-risk medical or other problems; serves as an index to the chart documentation
    SOAPIER (SOAPE documentation) an acronym for seven different aspects of POMR charting includes: SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN, INTERVENTION/IMPLEMENTATION, EVALUATION, REVISION
    SOAPE charting format used in POMR Components include SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLAN, and EVALUATION; briefer format for POMR
    charting by exception (CBE) recording only new data or changes in patient status or care; charting the exceptions to the previously recorded data
    Kardex/Rand card system used to consolidate patient orders and care needs in a centralized, concise way; kept at the nursing station for quick reference
    nursing care plan preprinted guidelines used to care for patients with similar health problems
    Subjective (S) information is what the patient states or feels; only the patient can provide this info
    Objective (O) info is what the nurse can measure or factually describe
    Assessment (A) refers to an analysis or potential diagnosis of the cause of a patient's problem or need
    Plan (P) general statement of the plan of care to be given or action to be taken
    Intervention/Implementation (I) specific care given or action taken
    Evaluation (E) an appraisal of the response and effectiveness of the plan
    Revision (R) includes the changes that may be made to the original plan of care
    incident report any event not consistent with the routine operation of a health care unit or the routine care of a patient
    clinical (critical) pathways allows staff from all disciplines to develop integrated care plans for a projected length of stay for patients of a specific case type
    computer-based records electronic medical records that facilitate delivery of patient care and support the data analysis necessary for strategic planning; eliminate repetitive entries and allow more freedom of access to the database
    Focus charting format Data
    Focus charting format Data Action Response / evalutation Education / patient teaching



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  2. #2
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    Default Documentation


    Documentation


    Question Answer
    Documenting and Reporting is The Process of preparing and recording all pertinent observations, interventions and responses relating to the complete record of a client's care; vital tool for communication among health care team members facilitates care
    The Purposes of Client Records Communication, Care planning, Legal documentation, Education, Research, Quality review Reimbursement
    Documentation of Care - Documentation of Care, Nursing Interventions, Patient Responses
    Guidelines for Documentation Agency policies govern method and frequency of charting used and who can write on the record Content should be accurate, concise, complete, relevant, sequential, orderly and factual, Format uses correct spelling, grammar, terminology
    Guidelines for Documentation Timely, with date and time of observations and follow-up noted, Accountable with each entry signed, Confidential; protected and secured for privacy at all times
    Methods of Documentation Source Oriented Records, Problem Oriented Medical Records, SOAP, (SOAPIE, SOAPIER)PIE, Focus Charting (DAR)Charting by Exception, Case Management Model
    Source Oriented Charting: Narrative Notations entered chronologically, Not organized by client's problems, Relevant information located in different areas of the chart, Each healthcare group keeps data on separate forms, Information fragmented
    Problem Oriented Medical Records (POMR) Organized around client's problems rather than sources of information, All heatlh care team members write information on the same forms, Progress notes focus on client's problems, Major parts of POMR - database, problem list, care plan, progress notes
    SOAP, SOAPIE, SOAPIER Subjective Data, Objective, Data, Assessment, Plan, Implementation, Evaluation, Response/Revise
    Select Problem e.g. Wound Infection S: patient states "my leg hurts", O: red open area observed on leg with purulent drainage, A: wound infection continues, P: clean wound and cover wtih a dressing, I: wound cleaned with NS and dry dressing applied, E: pt. states leg feels better, R: will m
    PIE: Problem, Intervention, Evaluation P - Client unable to walk to BR due to vertigo, I - Assisted pt to BR, BP assessed before, during and after ambulation, E - Patient able to walk to BR with assistance. BP 134/86 in ed, 100/70 dangling, 130/82 after ambulting, Orthostatic hypotension conti
    Focus Charting (DAR)Data- Action- Response Data, Action, Response, D - Pt. holding head and complaining of headache as 8 on 0 to 10 scale, A - Adminstered Tylenol 650 mg p.o. 1000, R - 10:30 am. pt. states pain decreased to 4 on 0 to 10 scale and is smiling
    Charting by Exception (CBE) Assumption: all predetermined standards are met w/normal response unless documented; Eliminates lengthy and repetitive narrative notes; Emphasizes only significant data & makes it easy to retrieve; Improved tracking of important patient responses
    Case Management Model Case manager is responsible for planning, coordinating care and consulting with other health care team members to ensure that patienTs are discharged in a timely manner; Focuses on care during an entire episode of illness across every setting where patien
    Computerized Records Client information is placed directly into computer and care plan developed on computer; Increase accuracy (standardized format); reduced time in documentation; Computers right at or near bedside or hand held systems; Facilitates storing and retrieval of
    Nursing Documentation Formats Initial nursing assessment; Health history & physical examination; Baseline database; Kardex/Patient care summary; Basic & Summarized patient information; Easily accessible by all team members
    Nursing Documentation Formats Nursing Care Plan; Nursing diagnoses, goals/outcomes, actions; Standardized but individualized for each patient; Critical Pathways; Charting is focused on expected outcomes for each day of care
    Nursing Documentation Formats Progress Notes; informs care givers of the progress patient is making toward achieved expected outcomes; Discharge or transfer summary; Reason for treatent, patient condition, level of goal achievement, instructions for continued care; Home health or Long
    Flowsheets Usually check off or fill in blank; Graphic/Clinical record, Vital signs, weight, BM's, I&O; 24-hour fluid balance record, intake and otuput per shift and total 24 hours; Medication adminstration Record, Records all medications given to patient, includes
    Legal Issues Follow guidelines for documentation; Must also be legible; Chronological order, no blanks; Black ink, no erasure or white out; Documentation is best legal defense
    Rule of Documentation Not Documented; Not DONE!!




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