LEC 6.1: Documentation | Purposes & Documentation Systems
Studied by 56 people
Learn
Practice Test
Spaced Repetition
Match
Flashcards1/56
There's no tags or description
Looks like no tags are added yet.
Name | Mastery | Learn | Test | Matching | Spaced |
|---|
No study sessions yet.
57 Terms
Health Insurance Portability and Accountability Act (HIPAA)
What law sets rules about patient privacy and confidentiality?
Documentation
Provides concrete evidence of the patients condition
Discussion
Informal oral consideration of subject by 2 or more healthcare personnel
Identify a problem or establish strategies to resolve a problem
Report
Oral, written, or computer-based communication intended to convey information to others
Incident Report
Example of a report
Used when there’s unexpected disasters or happenings to the patient. like patient falling out the bed
Record
Written or computer-based
Process of making an entry on a client is recording, charting, or documenting
Recording, charting, or documenting
Process of making an entry on a client
Chart/Client Record/Clinical Record
Formal, legal doc that provides evidence of a client’s care
All of these from clients have similar info
Protected Health Information (PHI)
Identifiable health information that is transmitted or maintained in any form or medium (including verbal discussion, electronic communication, written communication)
Log in and out computed with specialized password
What is used to ensure Confidentiality of Computer Records?
Communication
Planning Client Care
Auditing Health Agencies
Research
Education
Reimbursement
Legal Documentation
Health Care Analysis
8 Purposes of Client Records
Communication
One of the 8 Purposes of Client Records
Serves as a vehicle by which different health care professionals who interact with a client do this with each other
Planning Client Care
One of the 8 Purposes of Client Records
Each health care professional uses data from client’s record to plan for that client
Auditing Health Agencies
One of the 8 Purposes of Client Records
Review of client records for quality assurance
Research
One of the 8 Purposes of Client Records
Treatment plans for a number of client with the same health problems can yield information helpful in treating each other
Example: What medications, interventions worked for those with Alzheimers?
Education
One of the 8 Purposes of Client Records
Students in health disciplines often use client’s records as an educational tool
Reimbursement
One of the 8 Purposes of Client Records
For a facility to obtain government payment, client’s clinical record must contain the correct diagnosis - related group codes and reveal that the appropriate care has been given
Health Care Analysis
One of the 8 Purposes of Client Records
Information from records may assist health care planners to identify agency needs, such as overutilized and underutilized hospital services
Source-Oriented Record
Problem-Oriented Medical Record (POMR) Model
Problem, Interventions, Evaluation (PIE) Model
Focus Charting
Charting by Exception
Computerized Documentation
Case Management
7 Documentation Systems
Source-Oriented Record
One of the Documentation Systems
Is the traditional client record
Each person or department makes notations in a separate section or sections of the client’s chart.
In this type of record, information about a particular problem is distributed throughout the record.
Narrative Charting
Traditional part of the Source-Oriented Record
Consists of written notes that include routine care, normal finding, and client problems
Chronological order is frequently used but there’s not right or wrong order to the info
Narrative Charting (part of the Source Oriented Record)
What is shown?
Routine Care
Normal Findings
Client Problems
What written notes does Narrative Charting of Source Oriented Record include?
Convenient and easy to trace the information
What are the advantages of the Source-Oriented Record?
Information about a particular client problem is scattered throughout the chart
What are the disadvantages of the Source-Oriented Record?
Problem-Oriented Medical Record (POMR) or Problem-Oriented Record (ROR)
One of the Documentation Systems
Data are arranged according to the problems of the client
Members of the health care team contribute to the problem list, plan of care and progress notes
Consists of the Database, Problem List, Progress Notes
Database
Problem List
Progress Notes
What are 3 components of the Problem-Oriented Medical Record (POMR)/Problem-Oriented Record (POR)?
Database
What is the part of the POMR/POR that consists of all information known about the client when the client first enters the health care agency?
Problem List
What is the part of the POMR/POR that is derived from the database and serves as an index to the numbered entries in the progress notes?
Progress Notes
What is the part of the POMR/POR that are numbered to correspond to the problems on the problem list and may be lettered for the type of data?
SOAP (Subjective Data, Objective Data, Assessment, Planning)
What are the components of the Progress Notes for POMR/POR?
Problem, Interventions, Evaluation (PIE)
One of the Documentation Systems
Groups information into 3 categories (the acronym for this model)
Consists of a client care assessment flow sheet and progress notes
Flow Sheet
Progress Notes
What does the PIE model consist of?
Flow Sheet
What is the part of the PIE Model that uses specific assessment criteria in a particular format such as human needs or functional health patterns?
Progress Notes
What is the part of the PIE model in which after the assessment, the nurse establishes and records specific problems on these, often using NANDA diagnosis to word the problem?
Problem, Interventions, Evaluation (PIE) Charting
What documentation system is shown?
Eliminates traditional care plan and incorporates an ongoing care plan into progress notes
What is the advantage of the PIE Model?
Nurse must review all the nursing notes before giving care to determine which problems are current and which interventions were effective.
What is the disadvantage of the PIE Model?
Focus Charting
One of the Documentation Systems
Intended to make the client and client concerns and strengths the focus of care
Usually uses three columns for recording (Date & Time, Focusing, Progress Notes)
Date & Time
Focusing
Progress Notes
What are the 3 columns used in Focus Charting?
Data, Action, Response (DAR)
How are Progress Notes organized in Focus Charting?
Focus Charting
What is shown?
Charting by Exception (CBE)
One of the Documentation Systems
Only abnormal or significant findings or exceptions to norms are recorded
Incorporates 3 key elements (Flow sheets, standards of nursing care, and bedside access to chart forms)
Flow Sheets
Standards of Nursing Care
Bedside Access to Chart Forms
What are the 3 key elements incorporated in Charting by Exception?
Flow Sheets
One of the 3 key elements incorporated in CBE
Examples include graphic record, skin assessment record, fluid balance record, daily nursing assessment record, client teaching record, client discharge record
Graphic record
Fluid balance record
Daily nursing assessment record
Client teaching record
Client discharge record
Skin assessment record
What are examples of Flow Sheets incorporated in Charting by Exception?
Graphic Record
What is the Flow Sheet shown (incorporated in CBE)?
Charting By Exception
What documentation system is shown?
Skin Assessment Record
What is the Flow Sheet shown (incorporated in CBE)?
Standards of Nursing Care
One of the 3 key elements incorporated in CBE
Documentation by reference to the agency’s printed standards of nursing practice eliminates much of the repetitive charting of routine care
Bedside Access to Chart Forms
One of the 3 key elements incorporated in CBE
All flow sheets are kept at client’s ___ to allow immediate recording
Eliminates the need to transcribe data from the nurse’s worksheet to the permanent record
Computerized Documentation
One of the documentation systems
Computerized Clinical Record Systems are being developed as a way to manage the huge volume of information required in contemporary health care
Some institutions have a computer terminal or small handheld terminal
Computerized Documentation (using bedside computer)
What documentation system is being shown?
Computerized Documentation (using small handheld device)
What documentation system is being shown?
Case Management
One of the documentation systems
Emphasizes quality, cost-effective care delivered within an established length of stay
Uses a multidisciplinary approach to planning and documenting client care, using Critical Pathways
Critical Pathways
What does the Case Management Documentation System use to plan and document client care?
Critical Pathways (part of Case Management)
What component of a documentation system is shown?
