ATI DOCUMENTATION

Electronic Health Records (EHRs)

Systemic, digitized documentation system used to improve medical records, allowing sharing of client information among the interprofessional team.

Institute of Medicine (IOM) recommendation (1997)

Advocated for the nationwide adoption of EHRs to enhance health care safety.

Key advantages of EHRs

Facilitates continuous client care across facilities, enhances provider communication, reduces medical errors, and improves client care outcomes.

Scope of Practice

Involves documentation responsibilities shared among registered nurses, licensed practical nurses, and assistive personnel.

Health record

An individualized collection of health information about a client, including services provided, stored in electronic formats.

Problem-Oriented Medical Record (POMR)

An organized approach to client data that includes a database, problem list, initial plan, and progress notes.

SOAP documentation

A structured method for clinical observations in POMR consisting of Subjective, Objective, Assessment, and Plan.

PIE Model

Focuses on Problems, Interventions, and Evaluations, emphasizing ongoing care plans over traditional documentation.

Focus Charting

Documents client's specific health care problem, focusing on nursing diagnosis and changes in condition.

Charting by Exception (CBE)

Documents only unexpected findings according to standardized protocols, using a flowsheet and narrative form.

FACT acronym

Guide for high-quality documentation: Factual, Accurate, Complete, and Timely.

HIPAA Privacy Rule

Regulations established to protect the privacy of health care consumers, effective in 2003.

Verbal prescriptions

Prescriptions verbally provided by healthcare providers, necessitated only in emergency situations due to potential errors.

Health Information Technology for Economic and Clinical Health (HITECH) Act

Legislation aimed at improving client safety by promoting the installation of computerized provider order entry systems.

Clinical Decision Support System (CDSS)

A feature of CPOE systems that aids in prescribing medications by recommending doses and checking for interactions.