patients written on
paper, spoken aloud,
saved on computer “Name, address, phone, fax, social security
Reason the person is sick
Treatments patient receives”
Information about past health conditions
A nurse who fails to log off a computer after documenting patient care has breached patient confidentiality.
Sending confidential e-mail messages via public networks,
Sharing printers among units with differing functions,
Discarding copies of patient information in trash cans,
Holding conversations that can be overheard,
Faxing confidential information to unauthorized persons,
Sending confidential messages overheard on pagers
A patient has the right to obtain and review, but not revise the patient information in his or her health record.
Patient can update but not revise certain aspects of their health record.
Update their health record
Get a list of disclosures
Request a restriction on certain uses or disclosures
Choose how to receive health information
Read back the order to verify accuracy.
Date and note the time orders were issued in emergency.
Record VO, the name of the physician followed by nurse’s name and initials.
Sign orders with name, title, and pager number.
Date and note time orders signed.
Read orders back to practitioner to verify accuracy.
Date and note the time orders were issued.
Record TO, full name and title of physician or nurse practitioner who issued orders.
Sign the orders with name and title.
One of the purposes of creating a patient record is to evaluate the quality of care patients have received and the competence of the nurses providing that care.
Record of diagnostic and therapeutic orders
Quality of care reviewing
Legal and historical documentation
Serve as a financial and legal record.
Help in clinical research.
Support decision analysis.
“RULE: IF YOU DID NOT DOCUMENT YOU DID NOT DO IT!”
Zero after decimal point (i.e. 1.0)
Trailing zero (X.0mg)
Lack of leading zero (.X mg)
Problem-oriented medical records
Charting by exception
Case management model
Electronic medical records (EMRs)
A. Source-oriented records
B. Problem-oriented records
C. PIE (problem, intervention, evaluation)
D. Focus charting
PIE charting incorporates the plan of care into progress notes in which problems are identified by number.
In source-oriented records, each healthcare group keeps data on its own separate form.
Problem-oriented records are organized around patient problems rather than around sources of information.
Focus charting brings the focus of care back to the patient and the patient’s concerns.
Kardex and patient care summary
Plan of nursing care
Critical collaborative pathways
Discharge and transfer summary
Home healthcare documentation
Long-term care documentation
24-hour fluid balance record
24-hour patient care records and acuity charting form
A. Critical/collaborative pathways
B. Progress notes
C. Flow sheets
D. Discharge summary
Progress notes inform caregivers of the progress a patient is making using the specified formats.
Critical/collaborative pathways are standardized plans of care developed for a patient with designated diagnoses.
Flow sheets are documentation tools included in the progress notes that record routine aspects of care.
Discharge summaries are clinical reports written to summarize the patient record.
Rehabilitation potential is good (or patient is dying).
The patient’s status is not stabilized.
The patient is making progress in expected outcomes of care.
Resident assessment protocols
Taylor – pgs. 347-348
Residents residing for longer than 14 days.
Staff communication becomes more effective.
Resident and family involvement increases.
Documentation becomes clearer.
Current appraisal of each patient’s health status
(Changes in medical conditions and patient response to therapy
Where patient stands in relation to identified diagnoses and goals)
Current orders (nurse and physician) and unfilled orders
Summary of each newly admitted patient
Report on patient transferred or discharged
Nursing and interdisciplinary team care conferences
Nursing care rounds
Improvement in the nurse’s workflow and an elimination of redundant documentation
Automation of the collection and reuse of nursing data
Facilitation of the analysis of clinical data
Bedside medication system on PDA device
Vocere B2000 communications Badge
Page 352 Table 17-7 Taylor
Be honest and factual.
Also complete facility form and submit to quality control and supervisor.
As a nursing student and or new nurse ask someone experienced to assist you.
Tool used to document occurrence of anything out of the ordinary hat results in or has the potential to result in harm to a patient, employee, or visitor.
Helps ID RISKS.
Helps PREVENT future problems page 127-128 Taylor for example
many variations for different situations such as Nurse to Nurse, Nurse to Provider, Nurse to Radiology,