Healthcare Documentation Quiz

Documentation of Patient Care

• Purpose of documenting care type, time, and signature: Demonstrates interventions implemented to meet patient needs. It's not proof the signer performed all noted work, nor is it a guarantee against legal action by the patient.

Documentation's Significance in Managed Care

• Reimbursement: Facilities are reimbursed for documented patient care only. Reimbursement is based on diagnosis-related groups (DRGs) which predict resource use (length of stay, etc.) and provide a fixed payment amount.

Charting Systems

• Charting by Exception (CBE): Documents additional treatments, changes in patient condition, and new concerns.
• Incident Reports: Detail instances where care deviated from facility/national standards. Includes details of the event, time, injury, and who was notified.
• Critical Pathways: Integrated plans for projected patient length of stay, developed by all disciplines for a specific patient type.

Home Health Care Documentation

• Unique Challenges: Accessing records by multiple healthcare providers requires careful organization.

Long-Term Care Documentation

• Regulations: OBRA (Omnibus Budget Reconciliation Act) regulates documentation standards in long-term care.

Confidentiality and Medical Records

• Clinical Reason for Accessing Records: Nurses need a clinical reason to access patient records.
• Ownership of Records: The healthcare institution (or provider in private practice) owns the medical record.

Documentation in the Nursing Process

• Implementation Phase: Documentation is central to the implementation phase of the nursing process, as it details actual interventions.

Specific Charting Formats

• Focus Charting: A charting format that focuses on significant patient problems. Instead of problem lists, modified patient problems act as documentation index.
• SOAP Format: The problem-oriented medical record uses the acronym SOAPE (Subjective, Objective, Assessment, Plan, Evaluation or Progress note) to format and focus on patient problems.
• DARE: (Data, Action, Response, Education) combines aspects of assessment, planning, implementation, and evaluation within a focus charting system.

Quality Assurance and Improvement

• Quality Assurance/Assessment/Improvement (QA): QA evaluates care against accepted standards.
• Peer Review: Involves an in-house study evaluating the practice of individual nurses.

Errors in Documentation

• Correcting Errors: Draw a single line through the error, write ″error″ above it, and sign/initial the correction.
• General Rules: Chart consecutively, factually, and without speculation. Avoid retaliatory language.

Telephone Orders and Safety

• SBAR or SBARR: A communication method for telephone orders, focused on safety. The 'R' in SBARR is "read back"- to verify accuracy.

Inadequate Documentation and Malpractice

• Potential Causes of Malpractice Claims due to Inadequate Documentation: Incorrectly recording time, failing to record verbal orders, charting events in advance, and documenting incorrect dates.

Patient Records - General

• Critical Purposes: Written communication, permanence for accountability, legal record, teaching, and data/research collection.
• Content Needed for Providers: Care given, care planned, nursing problems, medical problems, incident reports, and patient response to treatments.

Malpractice Defense

• Accurate Documentation: Accurate records are critical in defending against malpractice claims.