Chapter 26: documentation and informatics study objective
1. Identify key reasons for reporting and recording patient care Communication
Auditing and Monitoring
2. Describe guidelines for effective documentation and reporting in a variety of health care settings
Accurate, concise, complete, specific, and timely.
a. A factual record contains descriptive, objective information about what a nurse sees, hears, feels, and smells. b. An accurate record uses exact measurements, contains concise data, contains only approved abbreviations, uses correct spelling, and identifies the date and caregiver. c. A complete record contains all appropriate and essential information. d. Current records contain timely entries with immediate documentation of information as it is collected from the patient. e. Organized records communicate information in a logical order.
3. Describe methods for multidisciplinary communication within the health care system Case management model of delivering care incorporates an interdisciplinary approach to documenting patient care and critical pathways are interdisciplinary care plans that include patient problems, key interventions, and expected outcomes within an established time frame Unexpected outcomes, unmet goals, and interventions not specified within the critical pathways time frame are called variances Ex: when a patient develops pulmonary complications after surgery, requiring oxygen therapy and monitoring with pulse oximetry. A positive variance occurs when a patient progresses more rapidly than expected (use of Foley catheter is discontinued a day early)
4. Identify common record-keeping forms.
(See Section Below: Page 8)
Most charts will include (Extra Notes):
Patient identification and demographic data
Informed consent for treatment and procedure
Nursing diagnosis or problems and nursing or interdisciplinary care plan Record of nursing care treatment and evaluation
Medical and health discipline progress notes
Physical assessment findings
Diagnostic study results
Summary of operative procedures
Discharge plan and summary
CH.26 Lecture Notes
Documentation is anything written or printed on which you rely as record or proof of patient actions and activities Information in the patient record provides a detailed account of the level of quality of care delivered to patients. The quality of care, the standards of regulatory agencies and nursing practice, the reimbursement structure in the healthcare system, and legal guidelines make documentation and reporting extremely important responsibilities of a nurse. Whether the transfer of a patient info occurs through verbal reports, written documents, or electronically, you need to follow basic principles to maintain confidentiality of information Confidentiality
Nurses are legally and ethically obligated to keep information about patients confidential Only staffs that are directly involved in a patients care have legitimate access to records. In most cases, patients are required to give written permission for release of medical information. HIPPA
EX. If you need a patient’s home number to reschedule an appointment, access to the medical record is limited solely to the telephone number. As a nursing student you must abide to the HIPPA standards of confidentiality and compliance and NEVER share information about patients with classmates or look into medical information about other patients. Standards
Standards of documentations differ within a healthcare...
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