Chap 17: DOcumenting, Reporting, Conferring and using informatics

• 1. See and copy their health record.
• 2. Update their health record.
• 3. Get a list of disclosures a healthcare institution has made independent of disclosures made for the purposes of treatment, payment and healthcare operations.
• 4. Request a restriction on certain uses or disclosures.
• 5 Choose how to receive health information.

• 1. U, write unit
• 2. IU, write international unit
• 3. Q.D., QD, qd, q.d., write daily
• 4. Q.O.D, etc, write every other day
• 5. trailing zero (X.0 mg), write X mg
• 6. Lack of leading zero (.X mg), write 0.X mg)
• 7. MS, MSO4 and MgSO4, write morphine sulphate of magnesium sulfate.

during a medical emergency when the attending MD is unable to write the order

Each healthcare group keeps data on its own seperate form (RN, MD, laboratory, x-ray tech)

notes written to inform caregiversof the progress a patient is making toward acheiving expected outcomes.

progress notes written by RNs that address routine care, normal findings, and pt problems identified in the plan of care.

Record that is organized around the PTs problems. Uses SOAP format.

• S - Subjective data
• O - Objective data
• A - Assessment
• P - Plan
• Organizes data entries in a POMR

• P - Problem
• I - Intervention
• E - Evaluation

the plan of care is incorporated into the progress notes in which problems are numbered in the order they are identified.

Holistic approach by focusing on the patient and the patients concerns. Uses DAR format.

• D - Data
• A - Action
• R - Response

Only significant findings are documented in narrative notes.

interdisciplenary documentation that select groups of patients are expected to acheive on each day of care.

specifies the plan of care linked to expected outcomes along a timeline.

used when a pt fails to meet expected outcomes. records the unexpected event, cause of the event, actions taken in response and discharge planning.

form used to record specific pt variables such as pulse, RR, BP, temp, weight, I&O, BM and other pt characteristics

• S - Situation: what is happening and why the patient is being handed off to another department.
• B - Background: what led up to the current situation
• A - Assessment: give your impression of the problem
• R - Recommendation: explain what you would do to correct the problem

Framework for communication between providers

• 1. Basic identifying info about the pt.
• 2. Current apprasial of the pt.
• 3. Current orders
• 4. Abnormal occurances in your shift
• 5. Unfilled orders
• 6. reports on pts that have been transfered or discharged.