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Chapter 16: Documenting, Reporting, Conferring and Using Infomatics Vocabulary
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- 13 methods of communication central to the nurse's professional role:documenting, reporting and conferring
- 2HIPAAHealth Insurance Portability & Accountability Act, protects the privacy of individually identifiable health information
- 3Write a progress note for each of these instances1. Upon admission, transfer to another unit, and discharge
2. When a procedure is performed
3. Upon receiving a patient post-operatively or post-procedure
4. Upon communicating w/physician regarding critical patient info (i.e. abnormal lab value)
5. For any change in patient status - 4Under HIPAA, patients have a right to1. see/copy/update their health record
2. get a list of the disclosures
3. request a restriction on certain uses or disclosures
4. choose how to receive health info - 5read backThe recipient reads back the message as they heard and interpreted it. the person giving the order confirms interpretation of the order is correct
- 6the RN who receives the order will1. record the order in the patient's medical records
2. read back the order
3. note date/time the orders were issued
4. Record VOs (verbal orders), physician or nurse practitioner who issued orders, followed by RNs initials/title - 7the physician who issed the VO1. reviews the order
2. signs, date/time the order - 8EHRElectronic Health Record. created when agencies under different ownership share their data
- 9EMRElectronic Medical Record. created by an agency/agencies having common ownership. not true EHR
- 10PHRPersonal Health Record. prepared online by patients to manage their health care.
- 11two types of PHRStandalone PHR and Tethered/Connected PHR
- 12Standalone PHRpatients fill in info from their own records; info is stored on patient's computer or the internet
- 13Tethered/Connected PHRlinked to a specific health care organization's EHR system or a health plan's information system
- 14HIEhealth information exchange allows doctors, nurses, pharmacists, other care providers, to securely access/share medical info electronically
- 15source oriented recordstraditional paper records in which each health care group keeps data on its own separate form
- 16progress noteswritten to inform caregivers of the progress a patient is making toward achieving expected outcomes
- 17narrative notesprogress notes written in a source-oriented record, address routine care, normal findings and patient problems identified in the plan of care
- 18POMRproblem oriented medical record: organized around the patient's problems rather than around sources of information. all health care professionals record information on the same form.
- 19SOAP formatSubjective data, Objective data, Assessment, Plan is used to organize entries in the progress notes of the POMR. originates from the medical record.
- 20PIE chartingProblem Intervention Evaluation: it doesn't develop a separate plan of care, it's incorporated into the progress notes. has a nursing origin. assessment performed @ beginning of each shift, problems are numbered and resolved problems dropped
- 21focus chartingbrings the focus of care back to the patient and their concerns
- 22DARData Action Response. used in the narrative portion of focus charting
- 23CBEcharting by exception. shorthand documentation method; only significant findings or exceptions are documented in narrative notes. limited usefulness when trying to prove that high-quality safe care was given
- 24collaborative pathways (critical pathways)used in the case management model. specifies the plan of care linked to expected outcomes along a timeline. CBE are frequently used w/this model.
- 25occurrence/variance chartingdone when a patient fails to meet an expected outcome or a planned intervention is not implemented. document the unexpected event, cause of the event, actions taken in response, and discharge planning (when appropriate)
- 26flow sheetsused to record routine aspects of nursing care
- 27graphic recordrecords specific patient variables such as pulse, respiratory rate, bp, temp, weight, fluid intake/output, bowel movements and other patient characteristics
- 28acuity recordsused to rank patients as high-to-low acuity in relation to both the patient's condition and need for nursing assistance or interventions. often used to determine staffing requirements
- 29OASISOutcome and Assessment Information Set: key component of Medicare's partnership with the home care industry to foster/monitor improved home health care outcomes
- 30RAIResident Assessment Instrument:
documentation in long-term care settings helps staff gather definitive information on a resident's strengths and needs, addressing them in an individualized plan of care - 31RAI consists of 4 basic components1. minimum data set
2. triggers
3. resident assessment protocols
4. utilization guidelines - 32ISBAR communicationa framework for communication between members of the health care team about a patient's condition
- 33ISBARI - identify/introduce:
S - Situation
B - Background
A - assessment
R - recommendation - 34ISBAR: Iidentify/introduce: communicate who you are, where you are, and why you are communicating
- 35ISBAR: Ssituation: communicate what is occurring and why the patient is being handed off to another department or unit
- 36ISBAR: BBackgrouund: explain what led up to the current situation and put in context if necessary
- 37ISBAR: AAssessment: give your impression of the problem
- 38ISBAR: RRecommendation: explain what you would do to the problem
- 39ISBARRLast R is for read-back of orders/response
- 40incident/variance reportdocument the occurrence of anything out of the ordinary that results in or has he potential to result in harm to a patient, employee or visitor
- 41nursing care roundsprocedures in which a group of nurses visit selected patients individually, at each patient's bedside. purpose is to gather information, help plan nursing care, evaluate nursing care patients received and provide them w/an opportunity to discuss their care. patient/family can participate. can make rounds with physicians to share the nursing's perspective
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- Descripción
- UNIT III: Person-Centered Care and the Nursing Process Chapter 16: Documenting, Reporting, Conferring and Using Infotmatics Vocabulary
- Creado por
- Alexandra Bozan · oct 2017
- Actualizado
- 3 oct 2017
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- 127
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