Chapter 26: Documentation

Health Records

Document including patient ID, demographic data, living wills, POA’s, informed consents, admission data, care plans, treatment record, medical history, diagnoses, orders, and progress notes

Diagnosis Related Groups

Classifications based on patient’s medical diagnoses that are used to establish medicare reimbursement

HIPPA

Health insurance portability and accountability act

Documentation Rules

Must be factual, accurate, current, organized, and complete

Banned Abbreviations

U (unit), IU (international unit), q.d (daily), q.o.d (every other day), MS/MSO4/MgSO4 (morphine sulfate or magnesium sulfate)

PIE

Nursing problem, intervention, and nursing evaluation

DAR

Focus charting, reports problem, includes data, response, and response

SOAP

Note taking method that includes subjective, objective, assessment, and plan

WNL

Within normal limits

Admission History Form

Form completed when a patient is admitted to a unit, provides baseline data

Patient Care Summary

Document generated at the beginning/end of each shift, includes info important for hand off

Discharge Summary

Preparation of patient for safe, effective, and timely discharge, includes medications, diet, community resources, follow up care, and person to contact in emergency

Acuity Rating System

System that determines the hours of care and number of staff required for a given group of patients every shift or every 24 hrs

Critical Pathways

Inter-professional care plans that identify patient problems, key interventions, and expected outcomes within an established time frame

Variances

Unexpected outcomes and interventions not specified in a critical pathway