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Chapter 26 with Audio


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Chapter 26 Documentation and Informatics Pame:

Chapter 26 Documentation and Informatics Pame


Confidentiality Nurses are legally and ethically obligated to keep client information confidential. Nurses are responsible for protecting records from all unauthorized readers. HIPAA act requires disclosure or requests regarding health information.

Standards :

Standards The Joint Commission requires each client have an assessment: Physical, psychosocial, environment, self-care, client education, and discharge planning needs Federal and state regulations, state statutes, standards of care, and accreditation agencies set nursing documentation standards.

Multidisciplinary Communication Within the Health Care Team:

Multidisciplinary Communication Within the Health Care Team Records or chart: Confidential permanent legal document Reports: Oral, written, audiotaped exchange of information Consultations: A professional caregiver providing formal advice to another caregiver Referrals: Arrangement for services by another care provider

Purposes of Records:

Purposes of Records Communication Legal documentation Financial billing Education Research Auditing/monitoring

Guidelines for Quality Documentation and Reporting:

Guidelines for Quality Documentation and Reporting Factual Accurate Complete Current Organized

Methods of Recording :

Methods of Recording Narrative: The traditional method Problem-Oriented Medical Record (POMR): Database Problem list Nursing care plan Progress note

Methods of Recording: Progress Notes:

Methods of Recording: Progress Notes SOAP: Subjective, objective, assessment, plan SOAPIE: Subjective, objective, assessment, plan, intervention, evaluation PIE: Problem, intervention, evaluation Focus Charting (DAR): Data, action, response

Methods of Reporting:

Methods of Reporting Source records: A separate section for each discipline Charting by exception (CBE): Focuses on documenting deviations Case management plan and critical pathways: Incorporates a multidisciplinary approach to care

Common Record-Keeping Forms:

Common Record-Keeping Forms Admission nursing history form Flow sheets and graphic records Client care summary or Kardex Acuity records Standardized care plans Discharge summary form

Home Care Documentation:

Home Care Documentation Medicare has specific guidelines for establishing eligibility for home care. Documentation is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance. Nurses need to document all their services for payment.

Long-Term Health Care Documentation:

Long-Term Health Care Documentation Governmental agencies are instrumental in determining the standards and policies for documentation. The Omnibus Budget Reconciliation Act of 1987 includes Medicare and Medicaid legislation for long-term care documentation. The department of health in states governs the frequency of written nursing records.

Computerized Documentation:

Computerized Documentation Software programs allow nurses to enter assessment data. Computers generate nursing care plans and document care. A complete computer-based patient care record (CPCR) is not without legal risks.


Reporting Change of shift Telephone reports Verbal or telephone orders Transfer reports Incident reports

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