Lesson 2 Documentation & Reporting

Documentation

A written or electronic legal record of all pertinent interactions with the patient.

Patient Rights

Patients have the right to see and copy their health record, update it, get a list of disclosures, request restrictions, and choose how to receive health information.

Confidentiality

All information about patients that must be kept private, including personal identifiers and health conditions.

Breach of Confidentiality

Actions that compromise patient confidentiality, such as displaying information publicly or sharing printers among different units.

ISBARR

A communication framework that stands for Identity, Situation, Background, Assessment, Recommendation, and Read back.

Focus Charting

A method of documentation emphasizing the patient's concerns and the healthcare provider's responses.

SOAP Notes

A method of documentation in healthcare consisting of Subjective, Objective, Assessment, and Plan sections.

Computerized Documentation/EHRs

Electronic health records used for efficient and secure patient documentation.

Verbal Orders (VO)

Orders given directly by a physician or nurse practitioner to a registered nurse, which must be documented accurately.

Purposeful Rounding

A nursing practice that involves intentional checking on patients to assess needs and ensure care is delivered.