DOCUMENTATION & INFORMATICS

the GHOST of RANKING DREAD!-jpegmafia

electronic health record (EHR)

a computerized, real time form of a client’s paper chart that can be shared between members of the interprofessional team (nurses, physicians, PT, OT, SLP, social services, imaging, and more). improves client care and healthcare outcomes, reduces medical errors, provides legal protection and clinical organization, and is compliant with HIPAA. includes patient information and clinical safety features (sepsis and vital sign alerts, med admin tracking, cross-facility care continuity).

problem-oriented charting

a comprehensive interdisciplinary format used by multiple members of the care team to document the same patient problem in one continuous record. used SOAP (subjective, objective, assessment, and plan).

source-oriented record

each discipline (nursing, physicians, therapy, etc.) keeps its own section of the chart rather than one shared narrative.

PIE format

problem, intervention, evaluation. tracks nursing care delivery by linking each problem directly to the intervention performed and the patients response.

focus charting format

data, action, response. centers on the nursing diagnosis and how the patient’s condition changes; useful for flagging shifts that need follow up.

charting by exception

uses standardized flowsheets and only requires a narrative note when the findings fall outside the normal range.

incidence reporting

used for falls and similar events. involves documenting what happened, the assessment performed, the provider notified, and any injuries sustained. this does not go in the medical record, but is instead used to address systemic issues for risk management.

FACT charting

factual, accurate, complete, timely. not a separate system, but a standard for writing high quality narrative notes within any format.

verbal/telephone prescriptions

verify the client and prescription, clarify the prescription if necessary, read-back the order, document, and implement the order. never take a verbal or telephone order for chemotherapy.

informatics

the use of information and technology to communicate, manage knowledge, mitigate error, and support decision making.

simulations

used to mimic real world experiences, for practice, assessment, education, or to acquire knowledge of students’ skills. helps nursing students build confidence and perform better.

clinical decision making

uses nursing knowledge to make a decision. assess patient situation, identify priority concerns, and use evidence based interventions.

clinical pathways

decision support tools that outline specific steps related to a predetermined clinical problem and present the anticipated clinical course. aid in quality improvement and improves patient outcomes

quality improvement

analyzing care practices to maintain the highest level of client care and outcomes.

HIPAA

law enacted to safeguard patient information and reduce fraud. includes several regulatory components (privacy rule, security rule, breach notification rule)

security rule

component of HIPAA developed as a response to cellular phones and personal technology, which are subject to being lost, hacked, or stolen.

breach notification rule

covers the process of reporting and responding to a breach of PHI. breaches should be reported to patients ASAP, but no more than 60 days from the breach. patients are informed via mail.

privacy rule

component of HIPAA that includes protected health information, which is any information held by a covered entity that can be linked to an individual. unique patient identifiers such as DOB and SSN have to be coded. prevents unauthorized use of this info and gives patients rights to their medical information.

enforcement rule

component of HIPAA that includes compliance and investigations, the administration of financial penalties for violations of HIPAA rules, and procedures for the investigation of these violations.

telehealth

the provision of both clinical and nonclinical aspects of health care delivery through the use of telecommunication devices such as the internet and telephone. remote patient monitoring is a form of this that assists in the tracking of client info and facilitates the rapid transfer of info to the health care provider

health literacy

the ability to obtain, read, and understand health-related information. significantly improves client outcomes. nurses must teach info in moments that favor patient education.