Basic Patient Care

  1. Confidentiality: What do nurses do, HIPAA requirements
    • Nurses are legally and ethically obligated to keep client information confidential.
    • Nurses are responsible for protecting records from all unauthorized readers.
    • HIPAA act requires disclosures or requests regarding health information standards.
  2. The Joint Commission requires each client have an assessment of:
    Physical, psychosocial, environment, self-care, client education, and discharge planning needs.
  3. Who sets nursing documentation standards?
    • Federal and state regulations
    • State statutes
    • Standards of care
    • Accreditation agencies
  4. The multidisciplinary communication within the health care team consists of:
    • Records or charts
    • Reports
    • Consultations
    • Referrals
  5. Records or charts are:
    confidential permanent legal documents
  6. What form of reports are available?
    oral, written, audiotaped exchange of information
  7. Consultations are:
    A professional caregiver providing formal advice to another caregiver.
  8. Referrals:
    • Arrangement for services by another care provider
    • Purposes of records
  9. Guidelines for Quality Documentation and Reporting
    • Factual
    • Accurate
    • Complete
    • Current
    • Organized
  10. Methods of recording:
    • Narrative: The traditional method
    • Problem-Oriented Medical record (POMR):
    • - Database
    • - Problem List
    • - Nursing care plan
    • - Progress note (e.g SOAP)
  11. Focus Charting consists of (DAR):
    • Data
    • Action
    • Response
  12. Methods of reporting consists of:
    • Source records: A separate section for each discipline
    • Charting by exception (CBE): Focuses on documenting deviations
    • Case management plan and critical pathways: Incorporates a multidisciplinary approach to care and has common record-keeping forms.
  13. Home Care Documentation:
    • Medicare has specific guidelines for establishing eligibility for homecare.
    • Documentation is the quality control and jstification for reimbursement from Medicare, Medicaid, or private insurance.
  14. Long-Term Health Care Documentation
    • Governmental agencies are instrumental in determining the standards and policies for documentation.
    • The Omnibus Budget Reconciliation Act of 1969 includes Medicare and Medicaid legislation for long-term care documentation.
    • The department of health in states governs the frequency of written nursing records.
  15. Computerized Documentation:
    • Software programs allow nurses to enter assessment data.
    • Computers generate nursing care plans and document care.
    • A complete computer based patient care record (CPCR) is not without legal risks.
  16. What needs to be reported?
    • Change of shift
    • telephone reports
    • verbal or telephone orders
    • transfer reports
    • incident reports
Card Set
Basic Patient Care
Documentation and Informatics