Documentation

Anything written or printed within a client record

A permanent legal writte ncommunication that includes information relevant to a client's health care management.

• Verbally
• Written
• Electronically

Only staff directly involved in patients' care.

Health Insurance Portability and Accountability Act - patient has the right to know what their records say, and must give permission in order for the records to be given to someone else. Pt must also be notified of who their records are going to.

confidentiality

The Joint Commission - an accreditation agency that specifies guildelines for documentation.

• Physical
• Psychosocial
• Environmental
• Self-care
• Client education
• Discharge planning

Federal and state regulations, state statutes, standards of care, and accrediting agencies

• Communication
• Legal documentation
• Financial billing
• Education
• Nursing process
• Research
• Auditing and monitoring

• Factual
• Accurate
• Complete
• Current
• Organized

Anything generalized such as "had a good day" or words like "seems"/"apparently". This type of documentation is subjective and does not reflect client assessmnet. Complete, concise descriptions of care should be used.

• The traditional method for recording nursing care. The use of a storylike format to document information specific to client conditions and nursing care.
• Disadv: repetitive, time-consuming, requires reader to sort through lots of info to find data

A method of documentation that emphasizes the pt's problems; data is organized by problem/diagnosis.

• Database
• Problem list
• Nursing care plan
• Progress notes

All available assessment info pertaining to the pt (ex, history, physical examination, lab reports, radiology test results, etc)

An organizing guide for a patient's care developed by healthcare team members (including client's physiological, psychological, social, cultural, spiritual, developmental, and environmental problems).

• The monitoring and recording of the progress of a patient's problems.
• Can come in various formats or structured notes

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• A method of progress report:
• S- Subjective data
• O- Objective data
• A- Assessment
• P- Plan
• I- Intervention
• E- Evaluation

• A method of problem-oriented progress reporting:
• P- problem
• I- intervention
• E- evaluation

• A method of focus charting:
• D- Data (both subjective & objective)
• A- action or nursing intervention
• R- response of the client

• Focus charting addresses client concerns such as a sign or symptom, a condition, nursing diagnosis, behavior, or significant event.
• Problem-oriented is more focused on a problem, and has more of a negative connotation.

• A documentation method that focuses on abnormal findings. It reduces documenting time and highlights trends/changes in the client's condition.
• The chart is mostly standardized, allowing the nurse to only have a need to document when there is a significant finding that strays from the norm.

A multidisciplinary approach to documentation. The critical pathways are care plans that include client problems, interventions, and expected outcomes within an established time frame. Nurses and other team members all can access the computerized critical pathway document to monitor the client's progress during each shift.

A form completed when a client is admitted to a nursing care unit. Provides baseline data to compare with changes in the client's condition.

• A form that allows nurses to quickly and easily enter assessment data about the client, including vitals and routine care (hygiene, ambulation, meals, safety/restraint checks).
• Used for their quick, easy reference in assessing a patient's status (commonly used in critical care and acute care)

• A computerized print-out for each patient during each shift. It is continually updated, providing a detailed list of orders, treatment, and diagnostic testing.
• Kardex - a portable file or notebook used for frequent updating and as a quick reference for the patient's status.

• A record to help determine the hours of care and staff required for a given group of patients. A patient's "acuity level" is based on the type and number of nursing interventions required over a 24-hr period.
• Depending on a patient's acuity level, the patient-to-staff ratio varies.

Preprinted, established guideline that is used to care for patients who have similar health problems.

• A summary form including all the information a patient needs at the time of discharge.
• Includes all learned information during their stay, such as about their disease process, likely signs/symptoms they may see, how to perform a certain procedure, and other resources they may need.

An unexpected outcome, unmet goal, or intervention not specified within a critical pathway timeframe.

• Transfer of information from the nurses on one shift to the nurse on the following shift.
• May also be given by a nurse to another health care provider.

• Information of a client's status or a change in status can be reported over the phone from another unit, or from another healthcare professional.
• Useful method to verify information
• Readback is required if critical values are being reported

• Involves a physician's stating a prescribed therapy over the phone to a registered nurse.
• Must be verified with a readback of the complete order.
• RN must also record it on an order sheet and sign it.

An order that should only be accepted when there is no opportunity for a physician to write the order, as in emergency situations

• A report of patient information from one unit to another (ex, from the ICU to the recovery room).
• Can be given by phone or in person

• An accurate list of all client meds from admission through to discharge.
• With each transfer within the institution, the list of meds must be reconciled for accuracy

• The integration of nursing science, computer science, and information sceince to manage and communicate data, information, and knowledge in nursing practice.
• Plays an important role in helping nurses make decisions more rapidly and more accurately