Questions and Answers
What are the five basic purposes for written patient records?
Written communication, permanent record for accountability, legal record of care, teaching, research and data collection.
What is a diagnosis-related group?
A system that classifies patients by age, diagnosis, and surgical procedure, producing 300 different categories used in predicting the use of hospital resources, including length of stay.
List the four common issues in malpractice caused by inadequate documentation.
- Not charting the correct time when events occurred, 2. Failing to record verbal orders or failing to have them signed, 3. Charting actions in advance to save time, 4. Documenting incorrect data.
Describe narrative charting and what is included in its implementation.
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What does the acronym SOAPIER describe?
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How is the format charting format used?
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What are the procedures a nurse should follow when filling out an incident report?
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Describe acuity charting and explain why it is used.
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Who has ownership and access to healthcare records?
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What are the major concerns regarding electronic documentation?
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Study Notes
Written Patient Records
- Five basic purposes: written communication, accountability, legal record of care, teaching, and research/data collection
Diagnosis-Related Groups
- Classifies patients by age, diagnosis, and surgical procedure
- Produces 300 categories for predicting hospital resource use, including length of stay
- Forms basis for cost reimbursement plans like Medicare and Medicaid
Malpractice Issues in Documentation
- Common issues include:
- Incorrect timing of recorded events
- Failure to record or sign verbal orders
- Charting actions ahead of time
- Documenting inaccurate data
Narrative Charting
- Involves recording patient care descriptively
- Includes basic patient problems, contacts made, care provided, and patient's response
SOAPIER Acronym for Charting
- S - Subjective
- O - Objective
- A - Assessment (cause of patient’s problem)
- P - Plan (care plan)
- I - Intervention/Implementation (actions taken)
- E - Evaluation (response appraisal)
- R - Revision (changes to original care plan)
Format Charting Use
- Utilizes a modified nursing diagnosis for documentation
- Emphasizes patient needs over medical diagnoses
Incident Reporting Procedures
- Document any unusual events affecting patient care
- Key points to include: date, time, care given, patient details, and notified physician
- Avoid mentioning the incident report in patient notes to protect legal standing
Acuity Charting
- Involves a scoring system to rate patients by illness severity
- Requires documentation of interventions to assess overall acuity
Healthcare Records Ownership and Access
- Original records are property of the institution or physician
- Patients typically lack immediate access to full records; access rights vary by state
- Lawyers can access records with patient consent
Concerns with Electronic Documentation
- Major issues include:
- Information overload
- Hidden information
- Lack of trust in data
- Communication barriers
- Decision-making challenges
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Description
This quiz focuses on essential aspects of healthcare documentation, including written patient records, diagnosis-related groups, and malpractice issues in documentation. Explore the narrative charting process and learn about the SOAPIER acronym for effective charting. Perfect for healthcare professionals and students.
