Chapter 3 Documentation PDF

Chapter 3 Documentation  Lesson 3.1: Documentation (Slide 1 of 2) 1. List the five purposes for patient records. 2. Describe the electronic health record (EHR) and the personal health record (PHR). 3. Determine when the use of Situation, Background, Ass...

Chapter 3 Documentation  Lesson 3.1: Documentation (Slide 1 of 2) 1. List the five purposes for patient records. 2. Describe the electronic health record (EHR) and the personal health record (PHR). 3. Determine when the use of Situation, Background, Assessment, and Recommendation is beneficial. 4. State important legal aspects of chart ownership, access, confidentiality, and patient care documentation. 5. Describe differences between traditional and problem-oriented medical records. 2  Lesson 3.1: Documentation (Slide 2 of 2) 6. Describe the basic guidelines for and the mechanics of charting. 7. Describe the differences in documenting care with activities of daily living and physical assessment forms, narrative, SOAPE, and focus formats. 8. Discuss documentation and clinical (critical) pathways. 9. Discuss home health care documentation. 10. Discuss long-term health care documentation. 11. Discuss issues related to computerization in documentation. 3  Purposes of Patient Records  Five basic purposes  Documented communication  Permanent record for accountability  Legal record of care  Teaching  Research and data collection  Audits  Diagnosis-related groups (DRGs)  Nurses’ notes 4  Electronic Health Record (EHR) and Personal Health Record (PHR)  Use of the record  Ease of use and documentation  Point-of-care  Computers on wheels (COWS)  Security 5  ISBAR  Identification, situation, background, assessment, and recommendation  Communicates between provider and nurse, nurse and nurse  Joint Commission recognizes it meets the National Patient Safety Goals 6  Basic Guidelines for Documentation  Quality and accuracy of the nurse’s notes are extremely important  Correct spelling, grammar, and punctuation, as well as good penmanship and other writing skills are important in documentation  Information recorded in the chart should be clear, concise, complete, and accurate  The registered nurse (RN) is responsible for the initial admission nursing history, physical assessment, and development of care plan 7  Recording Methods  Traditional chart  Narrative  Problem-oriented medical record (POMR)  Focus charting  Charting by exception  Alternative forms  Kardex/Rand  Nursing care plans 8  Other Documentation Forms  Incident reports  24-hour patient care reports and acuity forms  Acuity charting  Discharge summary 9  Documentation and Clinical (Critical) Pathways  Clinical pathways  Coordinates medical and nursing interventions  All disciplines develop integrated care plans for projected length of stay for specific case type  Monitor patient’s progress and a documentation tool 10  Home Health Care Documentation  Documentation provides quality control and reimbursement from Medicare, Medicaid, and private insurance companies  Must note patient education and demonstration of learning  Coordination of services and compliance of regulation reflected by all members of the health care team 11  Long-Term Health Care Documentation  Omnibus Budget Reconciliation Act (OBRA) of 1987 regulates standards for resident assessment, individualized care plans, and qualifications for health care providers  Department of Health (DOH) for each state governs frequency of written nursing records of residents  Supports multidisciplinary approach in assessment and planning processes of patient care 12 Special Issues in Documentation  Record ownership and access  Confidentiality  Electronic documentation  Use of fax machines 13