Documentation in Nursing Care

This set of vocabulary flashcards covers the fundamental concepts, legal requirements, and types of documentation used in nursing care as outlined in Chapter 5.

Continuity of Care

The nurse's responsibility to document an ongoing account of all pertinent patient data for 24 hours to provide the health-care team with a complete picture for decision-making.

Accountability

The use of documentation to detect weaknesses in delivery systems, verify facility compliance through audits, and provide proof for insurance reimbursement.

Legal Record

A permanent record that can be used in a court of law to prove or disprove malpractice or negligence; based on the principle, 'If it wasn’t charted, it wasn’t done.'

Confidentiality Violation

Occurs when personal information is provided to another person without the patient’s permission or knowledge, such as confirming an individual is a patient without specific permission.

HIPAA (Health Insurance Portability and Accountability Act)

Regulations stating that all information in a chart belongs to the patient, giving them the right to view, copy, and amend their own health information.

Incident Report

Also known as a variance report; used to document accidents, mistakes, or out-of-the-ordinary occurrences without including judgment, opinion, or reference to the report in the patient's medical record.

Care Plan

A document that communicates the patient’s problems, the interventions to be performed, and the effectiveness of those interventions.

Source-Oriented Records

Medical records organized according to the type of data using specific forms and labeled tabs, making it easy to locate specific results but difficult to see the whole picture.

Problem-Oriented Records

Records organized around individual problems consisting of four primary sections: Database, Problem list, Plan of care, and Progress notes.

Narrative Charting

A method of recording patient information that tells a story in chronological order, providing a description of conditions, complaints, and treatments.

Electronic Health Record (EHR)

A record of an individual’s lifetime health information that is easily updated, transferable, and includes tests, appointments, medications, and immunizations.

Kardex

A quick reference used in long-term care that contains physician’s and nursing orders for a resident on a single page.

Home Health Documentation

Records that are regulated and audited by both the state health department and Medicare, documenting visits performed by an RN or LPN.

Malpractice Risks in Documentation

Five major mistakes including failure to document assessment findings, medications administered, pertinent health history, physician's orders, or documenting on the wrong chart.