anything written or printed relating to the client, that you rely on as record or proof for authorized persons.
diagnosis-related group (DRG)
clients are grouped together by diagnosis, surgical procedures, complications, preexisting conditions, age and everything done for a client must be documented in the medical record so that the health care institution can recover its costs.
nurses are legally and ethically obligated to keep information about clients confidential.
legislation that protects client privacy for health information. (requires disclosure or requests regarding health information.)
The Joint Commission
requires documentation within the context of the nursing process. requires that accredited hospitals have written nursing policies and procedures and quality improvement programs. requires multidisciplinary plan. (expand..)
American Nurse Association
improves standards of health and the availability of health care, to foster high standards for nursing, and to promote the professional development and welfare of nurses.
federal/state regulations, state statues, standards of care, accreditation agencies
all together set nursing documentation standards.
confidential, permanent legal documentation of information relevant to a client's health care.
oral, written or audiotaped exchanges of information between caregivers. (change of shift, telephone, transfer, incident)
1)Situation (state problem and chief complaints) 2)Background (admitting dx, current meds, allergies, lab results, important info.) 3)Assessment 4)Recommendation
communication, legal documentation, financial billing, education, research, auditing - monitoring
main purposes of records for patients.
traditional method for recording that uses storylike format to document information specific to client conditions and nursing care.
problem-oriented medical record (POMR)
method of documentation that emphasizes the client's problems. Data is organized by problem or diagnosis. Includes: 1)Database 2)Problem list 3)Nursing care plan 4)Progress notes
1)Subjective data 2)Objective data (measured and observed) 3)Assessment (diagnosis based on data) 4)Plan (what caregiver plans to do)
1)Problem 2)Intervention 3)Evaluation
originates from nursing diagnosis, rather than medical diagnosis. Notes are numbered according to client's problems. Continuing problems documented daily.
DAR (Focus charting)
1)Data (both subjective and objective) 2)Action of nursing intervention 3)Response of the client (evaluation of effectiveness)
-incorporates all aspects of nursing process, highlights client concerns and can be integrated in any clinical setting.
client's chart has a separate section for each discipline to record data. (ex. nursing, medicine, social work, respiratory therapy)
charting by exception (CBE)
focuses on documenting deviations from the established norm or abnormal findings.
advantage- caregivers can easily locate each section to document entries. disadvantage- client's problems are distributed across the record.
advantage- reduces documentation time and highlights trends or changes. disadvantage- system can pose legal risks if nurses do not document.
model of delivering care that incorporates a multidisciplinary approach to documenting client care.
multidisciplinary care plans that include client problems, key interventions, and expected outcomes within an established time frame.
unexpected outcomes, unmet goals, and interventions not specified within the critical pathway time frame.
forms that allow nurses to quickly and easily enter assessment data about the client. (ex. vital signs, hygeine, ambulation, meals, weight, etc.)
computerized system that provides basic summative information in the form of client care summary that is printed for each client each shift for easy reference.
standardized care plans
pre-printed established guidelines that are used to care for clients with similar health problems, that are based on the institution's standard of nursing practice.
quality control and justification for reimbursement from Medicare, Medicaid or private insurance.
instrumental in determining the standards and policies for documentation in long-term health care.