Concepts: Health and Wellness / Documentation

disease

Historically health and wellness was considered to be the opposite or absence of ___. today it is a multidimensional concept

health promotion and disease prevention

The Healthy People: The surgeon General's Report on Health Promotion and Disease Prevention (first published in 1979)

-Goals for improving national health by 1990

-More focus on ___ and ___—instead of illness care

-deaths, disabilities, and diseases

-child immunization

-infant mortality

-CAD and stroke

The Healthy people 2000 (published 1990) goals were:

-to reduce preventable ___, ___, and ___. Goal was not to eliminate but to reduce the number

-increase ___

-decrease ___

-decrease incidence of ___ and ___

-quality and years

-health disparities

Healthy People 2010 had overarching goals which were:

-To increase ___ and ___ of healthy life

-To eliminate ___

-healthy behaviors

-safe community

-personal and public health

-reducing disorders and diseases

-free

-social and physical

Healthy People 2020 Goals

-Attain high-quality, longer lives ___ of preventable disease, disability, injury, and premature death

-Achieve health equity, eliminate disparities, and improve the health of all groups

-Create ___ and ___ environments that promote good health for all

-Promote quality of life, healthy development, and healthy behaviors across all life stages

health

___ is a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity

physical, mental, and social

Health is a state of complete ___, ___, and ___ well-being, not merely the absence of disease or infirmity

values, personality, and lifestyle

Health is a state of being that people define in relation to their own ___, ___, and ___

-Negative or Positive

-Pessimistic or Optimistic

-Naive

what are 3 ways your attitudes towards life can be

total person and living environment

Nurses' Attitudes toward Health & Illness considers what 2 things to individualize care?

-Education

-Culture

-Social Conditions

what are the 3 parts to someones lifestyle (in defining health)

model

A ___ is a theoretical way of understanding a concept or idea

health and illness

Models used to understand relationships between concepts of ___ and ___

health and health behaviors

Models used to understand the patient's attitudes toward ___ and ___.

-ideas

-convictions

-attitudes

what are the 3 parts to health belief

attitudes

___ are beliefs which usually influence health behaviors

positive or negative

attitudes can be a ___ or ___ influence on health behavior

beliefs and behaviors

Health Belief Model - Rosenstock's (1974) and Becker and Maiman's (1975)addresses the relationship between a person's ___ and ___

Health Belief Model - Rosenstock's (1974) and Becker and Maiman's (1975)

___ helps you understand factors influencing patients perception, beliefs, and behaviors to care plan that will most effectively help patients maintain or restore health and prevent illness

Health Promotion Model

___ defines health as a positive, dynamic state, not merely the absence of disease

Health Promotion Model

___ was proposed by Pender was designed to be a "complementary counterpart to models of health protection". It defines health as a positive, dynamic state, not merely the absence of disease.

Maslow's Hierarchy of Needs

___ is used to understand the interrelationships of basic human needs

physiological, safety and security, love and belonging, self-esteem, self actualization

what are the 5 levels of Maslows

Holistic Health Model

___ attempts to create conditions that promote optimal health

mind, body, and soul

what are the 3 parts to the holistic health model

-developmental stage

-intellectual background

-perception of functioning

-emotional factors

-spiritual factors

what are the 5 internal variables influencing health

developmental stage

___ is an internal variable and it is the comprehension of concepts and emotional development

Intellectual Background

___ is an internal variable and it is knowledge or misinformation, and cognitive abilities

Perception of Functioning

___ the way people perceive their physical functioning affects health beliefs and practices

level of fatigue

what is an example of perception of functioning

emotional factors

___ is the patient's degree of stress, depression, or fear can influence health beliefs and practices

degree of calm or stress

what is an example of emotional factors

Spiritual factors

___ is how a person lives his or her life, including the values and beliefs exercised, the relationships established with family and friends, and the ability to find hope and meaning in life

-family practices

-socioeconomic factors

-psychosocial factors

-cultural background

what are 4 external variables influencing health

-marriage stability

-lifestyle

-occupational environment

-economically disadvantage

what are 4 psychosocial variables that are apart of the external variables influencing health

health promotion

___ are activities to maintain or enhance present levels of health such as working out and eating healthy

wellness

___ is education to teach how to live a healthy life

wellness

teaching portion size, what to eat, and moderation are ___

health promotion

working out and eating healthy are___

illness prevention

___ protects from actual or potential health threats

illness prevention

vaccines is a ___

-primary prevention

-secondary prevention

-tertiary prevention

what are the 3 levels of preventive care

primary prevention

___ is the true prevention that lowers the chances that a disease will develop

secondary prevention

___ focuses on those who have a disease or are at risk to develop complications or worsening conditions

tertiary prevention

___ occurs when a defect or disability is permanent or irreversible

risk factors

___ are variables that increase the vulnerability of an individual or a group to an illness or accident

-genetic and physiological factors

-age

-environment

-lifestyle

risk factors include what 4 things

illness

___ is a state in which a person's physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished or impaired

NOT

illness is ___ similar to disease

acute illness

___ has a short duration and severe; includes symptoms

CAN

acute illness ___ be reversible

chronic illness

___ persists longer than 6 months and affects functioning in one or more systems

CAN NOT

chronic illness ___ be reversible

illness behavior

___ involves how people monitor their bodies and define and interpret their symptoms

-Internal variables: Perception of illness and nature of illness

-External variables: Visibility of symptoms, social group, cultural background, economics, and accessibility to health care

what are 2 factors influencing illness and illness behavior

behavior and emotional

___ and ___ changes depend on nature of illness, patient's attitudes, and varies depending on type of illness

individualized

Each patient responds uniquely to illness, and therefore nursing interventions must be ___

1. shock

2. withdrawal

3. acknowledgment

4. acceptance

5. rehabilitation

what are the 5 phases of illness

self concept

___ is a mental self-image of strengths and weaknesses in all aspects of personality

psyche

self concept includes aspects of the ___ and the spirit of man; it is more complex and less readily observed than role changes

-Wage earner

-Decision maker

-Professional

-Child

-Sibling

-Parent

what are 6 roles that are impacted by illness

role reverse (oldest child becomes parent, etc)

what is a role change that is seen with illness

family dynamics

___ is the process by which family functions, makes decisions, gives support to individual members, and copes with everyday changes and challenges

admission

When does discharge planning begin?

medical health record

-Administrative and billing data

-Patient identification and demographic data

-Existence of "Living Will" or "Durable Power of Attorney for Healthcare" documents

-Informed consent

-Admission data

-Nursing diagnoses or problems

-Record of nursing care treatment and evaluation

-Medical history

-Medical diagnoses

-Therapeutic orders, including code status (provider order for "Do Not Resuscitate")

-Medical and interdisciplinary progress notes

-Physical assessment findings

-Diagnostic study results

-Patient education

-Summary of operative procedures

-Discharge summary and plan

These are contents of a ___

documenting

___ is the process of making an entry on a patient record

recording or charting

documenting is also called what 2 other things

-Auditing/monitoring

-Communication

-Education

-Legal documentation

-Reimbursement

-Research

what are the 6 purposes of a medical record?

HITECH

___ established provisions to promote the meaningful use of health information technology (HIT) to improve the quality and value of health care

electronic health record (EHRs)

Experts believe that implementing ___ across the health care delivery system will decrease costs and improve the quality of patient care

Electronic Health Record (EHR)

___ is a digital version of patient data and it is a longitudinal (lifetime) record of all health care encounters

Electronic Medical Record (EMR)

___ is a legal record that describes a single encounter or visit created in hospitals and outpatient health care settings

-retrieval

-chronic

Electronic Health Records

-Demonstrate improved patient outcomes

-Allow data ___

-Measures nursing outcomes

-___ diseases managed more effectively

-Improves interprofessional communication and clinical decision-making

confidential

Nurses are legally and ethically obligated to keep all patient information ___

HIPPA

Nurses are responsible for protecting records from all unauthorized readers. ___ requires that disclosure or requests regarding health information be limited to the minimum necessary

communicate

The quality of patient care depends on your ability to ___ with other members of the health care team. When a plan is not communicated to all members of the health care team, care becomes fragmented, tasks are repeated, and delays or omissions in care often occur.

Physical security

Electronic documentation has legal risks. Most security mechanisms for computerized information systems use a combination of logical and physical restrictions to protect information. ___ measures include placing computers or file servers in restricted areas or using privacy filters for computer screens visible to visitors or others without access.

safe gaurd

You must ___ any information that is printed from the record or extracted for report purposes. De-identify all patient data. Special considerations for faxing

legal

-Start with date and end with signature & title -fill in space

-Record all facts

-Legible and in correct color ink

-Chart only for self

-Protect security of password

-Do not erase

-Do not write derogatory statements

-Do not leave blank spaces

-Do not remove mistakes from chart (dont throw away document if you spills something on it)

these are ___ do's and dont's

National Committee for Quality Assurance (NCQA) and TJC

Conform to standards of the ___ and ___ to maintain institutional accreditation and minimize liability

-Factual

-Accurate

-Complete

-Current

-Organized

What are the guidelines for quality documentation?

factual

-What you feel, see, hear, & smell

-Paint a picture

-Describe in words so the reader can visualize what you did

-Let the reader form an opinion from your description

-Clearly describe patient behaviors

-Avoid including own opinions, assumptions, or conclusions

these are guidelines to follow to report ___ information

correct

2/8/19 0900 Restless & pacing around the room. Shouting at the nurses, "just leave me alone." Assisted to chair. Encouraged to take deep breath...................................Brian Trevor, BSSN-LU

This is an example of the ___ way to chart

incorrect

2/8/19 0900 Irritable & stressed out this am. Being very uncooperative. Encouraged to move chair by windows and call friends.... .......................................................Brian Trevor, BSSN-LU

this is an example of the ___ way to chart

good, average,

These are ways to be specific, accurate, and complete

-Include all relevant information precisely & in sufficient detail

-Avoid the use of words such as ___, ___, normal, & sufficient

-Use precise measurements when appropriate

-Spell out abbreviations in their entirety

-Watch for spelling errors

correct

2/10/19 1000 Oral fluid intake 300 ml water. Ate 75% food. Abdominal wound 5 cm in length, clean, dry and intact. Edges approximated. ...........................................James Brown, BSSN-LU

This is an example of the ___ way to chart

incorrect

2/10/19 1000 Drank an adequate amount of fluid. Wound large & gaping. Appetite good..........................James Brown, BSSN-LU

This is an example of the ___ way to chart

-draw line through

-write "error" above with name and DOB

-never scratch out, erase, or use correction fluid

what is the correct way to correct errors properly

make a late entry

what do you do if you forget to chart something?

not

When a pertinent entry was missed or not written in a timely manner, a late entry should be used to record the information in the medical record. Identify the new entry as a "late entry". Enter the current date and time. Identify or refer to the date and incident for which late entry is written. When using late entries document as soon as possible. There is ___ a time limit to writing a late entry, however, the more time that passes the less reliable the entry becomes.

block charting

you should avoid ___ which is documenting in paragraph form everything that happened for entire shift; Focus on important aspects of care, but can easily omit important information; Inadequate when describing event that require timing (i.e. care of unstable patient)

block charting

Assisted with morning care. Ambulated in hallway with one assist. Medicated with Tylenol 650mg for pain in left hip. States "relief obtained with pain medication." Dr. Asha visited. Dressing changed. Transported to physical therapy for heat therapy....................................Nate Jackson, BSSN-LU

this is an example of ___

-narrative

-problem oriented medical record (POMR)

what are the 2 methods of documentation

narrative

___ is the traditional method of documentation

Narrative

___ format consists of the use of a story-like format to document information specific to patient condition & nursing care. this allows nurse to record what she sees in her own words

problem-oriented medical record (POMR)

___ documentation system organized according to the person's specific health problems; includes database, problem list, plan of care, and progress notes

-Data base

-Problem list

-Care plan

-Progress notes (Use SOAP, SOAPIE, SOAPIER, focus charting (DAR))

problem-oriented medical record (POMR) contains what 4 things

Charting by exception (CBE)

__ is a shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes

interdisciplinary

with the case management model we incorporate an ___ approach to care

-Reflect course of treatment for the average patient with a given diagnosis or procedure

-Assist with improvement of quality and efficiency of care

-Establish sequence and timing of interprofessional activities

-Eliminates nurses' notes, flow sheets, and nursing care plans

-Variances

what are the 5 critical pathways of case management