01 A Documentation #1 flashcards |

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anything written or printed relating to the client, that you rely on as record or proof for authorized persons.


specify guidelines for documentation. (The Joint Commission)

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.

record (chart)

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)


professional caregiver providing formal advice to another caregiver.


arrangement for services by another care provider.


1)Situation (state problem and chief complaints) 2)Background (admitting dx, current meds, allergies, lab results, important info.) 3)Assessment 4)Recommendation


have become the basis for establishing reimbursement for client care.

communication, legal documentation, financial billing, education, research, auditing - monitoring

main purposes of records for patients.

proper documentation

best defense of legal claims associated with nursing care.

narrative documentation

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)SOAP 2)PIE 3)Focus Charting (DAR)

3 Formats for Progress Notes method

SOAP format

1)Subjective data 2)Objective data (measured and observed) 3)Assessment (diagnosis based on data) 4)Plan (what caregiver plans to do)

PIE format

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.


1)Subjective data 2)Objective data 3)Assessment 4)Plan 5)Intervention 6)Evaluation

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.

source record

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.

source record

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.

case management

model of delivering care that incorporates a multidisciplinary approach to documenting client care.

critical pathway

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.

flow sheet

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.

acuity records

way to determine the hours of care and staff required for a give group of clients.

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.

governmental agencies

instrumental in determining the standards and policies for documentation in long-term health care.

Omnibus Budget Reconciliation Act (1987)

includes Medicare and Medicaid legislation for long-term documentation.

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