Chapter 16: Documenting, Reporting, Conferring and Using Infomatics Vocabulary

Alexandra Bozan
Flashcards by , created about 2 years ago

UNIT III: Person-Centered Care and the Nursing Process Chapter 16: Documenting, Reporting, Conferring and Using Infotmatics Vocabulary

Alexandra Bozan
Created by Alexandra Bozan about 2 years ago
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Question Answer
3 methods of communication central to the nurse's professional role: documenting, reporting and conferring
HIPAA Health Insurance Portability & Accountability Act, protects the privacy of individually identifiable health information
Write a progress note for each of these instances 1. 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
Under HIPAA, patients have a right to 1. 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
read back The recipient reads back the message as they heard and interpreted it. the person giving the order confirms interpretation of the order is correct
the RN who receives the order will 1. 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
the physician who issed the VO 1. reviews the order 2. signs, date/time the order
EHR Electronic Health Record. created when agencies under different ownership share their data
EMR Electronic Medical Record. created by an agency/agencies having common ownership. not true EHR
PHR Personal Health Record. prepared online by patients to manage their health care.
two types of PHR Standalone PHR and Tethered/Connected PHR
Standalone PHR patients fill in info from their own records; info is stored on patient's computer or the internet
Tethered/Connected PHR linked to a specific health care organization's EHR system or a health plan's information system
HIE health information exchange allows doctors, nurses, pharmacists, other care providers, to securely access/share medical info electronically
source oriented records traditional paper records in which each health care group keeps data on its own separate form
progress notes written to inform caregivers of the progress a patient is making toward achieving expected outcomes
narrative notes progress notes written in a source-oriented record, address routine care, normal findings and patient problems identified in the plan of care
POMR problem 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.
SOAP format Subjective data, Objective data, Assessment, Plan is used to organize entries in the progress notes of the POMR. originates from the medical record.
PIE charting Problem 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
focus charting brings the focus of care back to the patient and their concerns
DAR Data Action Response. used in the narrative portion of focus charting
CBE charting 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
collaborative 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.
occurrence/variance charting done 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)
flow sheets used to record routine aspects of nursing care
graphic record records specific patient variables such as pulse, respiratory rate, bp, temp, weight, fluid intake/output, bowel movements and other patient characteristics
acuity records used 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
OASIS Outcome and Assessment Information Set: key component of Medicare's partnership with the home care industry to foster/monitor improved home health care outcomes
RAI Resident 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
RAI consists of 4 basic components 1. minimum data set 2. triggers 3. resident assessment protocols 4. utilization guidelines
ISBAR communication a framework for communication between members of the health care team about a patient's condition
ISBAR I - identify/introduce: S - Situation B - Background A - assessment R - recommendation
ISBAR: I identify/introduce: communicate who you are, where you are, and why you are communicating
ISBAR: S situation: communicate what is occurring and why the patient is being handed off to another department or unit
ISBAR: B Backgrouund: explain what led up to the current situation and put in context if necessary
ISBAR: A Assessment: give your impression of the problem
ISBAR: R Recommendation: explain what you would do to the problem
ISBARR Last R is for read-back of orders/response
incident/variance report document 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
nursing care rounds procedures 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