Documentation

What is an electronic health record (EHR)?

A computerized, real-time form of a client's chart that can be shared among the interprofessional team.

What information can an EHR contain?

Medical history, diagnosis, allergies, diagnostic testing results, and other care information.

Why are EHRs useful?

Information is readily available so providers can make care decisions quickly.

What documentation methods are listed in the lecture?

Source-oriented records, problem-oriented records, SOAP notes, PIE, focus charting, and charting by exception (CBE).

What does SOAP stand for?

Subjective, Objective, Assessment, Plan.

What does PIE stand for?

Problem, Intervention, Evaluation.

What does focus charting use?

DAR: Data, Action, Response.

What is charting by exception (CBE)?

Documenting unexpected findings rather than every normal finding.

What should happen during EHR downtime?

Use paper forms, follow facility protocols for identification/reporting, avoid scrap paper, and do not delay documentation.

What does FACT stand for in high-quality nursing documentation?

Factual, Accurate, Complete, Timely.

What does 'Factual' documentation mean?

Concrete, objective, descriptive information based on direct observation and measurement.

What does 'Accurate' documentation mean?

Exact descriptions and measurements that provide concrete data for comparison over time.

What does 'Complete' documentation mean?

Include what, when, where, why, and how; information must be unbiased.

What does 'Timely' documentation mean?

Chart in chronological order and as close to the event as possible; do not wait until the end of the shift.

What general style should nursing documentation use?

Factual, nonjudgmental, timely, and standard accepted terminology/language.

Who may take verbal or telephone orders according to this lecture?

An RN, according to facility policy—not an LPN or UAP.

How should a verbal/telephone order be confirmed?

Repeat the order back to the provider verbatim.

What must be entered in the EMR for a verbal order?

Indicate it is a verbal order and include provider name, date, time, and RN name.

Why are verbal chemotherapy orders generally not allowed?

They are high risk.

What is the first step when legal counsel is sought?

Acquire a copy of the entire medical record.

How is a handwritten documentation error corrected?

Draw a single line through the error, write 'error,' and initial it.

How is an electronic documentation error corrected?

Correct it on the screen and add a comment or addendum.

What does EHR log-on access allow facilities to track?

Who accessed the record and what they did in it.

What are nurses legally/ethically required to do with documentation?

Document care accurately and completely and protect confidentiality/privacy, including HIPAA requirements.