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Documentation
Ch. P Potter/Perry
| Question | Answer |
|---|---|
| What is documentation | anything written or printed in pxt record |
| What are the current documentation stantards? | physical assess, psychosocial, envitonmental, self care knowl, discharge plan |
| If not charted then | not done |
| What is a record | Legal document, continuing acct of pxts care status |
| What is a report | oral,written,audiotaped xchng of info ex: change of shift, telephone, xfer,incident |
| What are DRG's | diagnosis related groups r basis for reimbursement. Documentation verifies nursing care given |
| what is needed to collect data from pxt records | consent form |
| What r purposes of documentation | communication,legal documentation,reimbursement,education,research,auditing,monitoring |
| What statisical data is found in pxt records? | freq of clinical disorders,complications,specific therapies,recoveries,mortality |
| 5 common malpractice issues | 1.failure to document correct time of events 2.failure to record verbal orders/sign orders 3.charting in advance 4.documentin incorrect data 5.fail to give report or incomplete report to next shift |
| What r methods of recording? | narrative and problem oriented (POMR),SOAP(IE),PIE,Focus |
| What is SOAP? | subjective-verbalization of pxt objective- data measure/observed assessment- diagnosis from subj/obj plan- what caregiver plans to do |
| What is SOAPIE | subj,obj,assess,plan,intervention,evaluation |
| what is PIE documentation? | problem oriented from nursing origin problem- nursing diag of pxt intervention-actions taken evaluation-outcomes of nursing interventions |
| What is Focus recording | focus on pxt concerns DAR-data,actions,pxt response |
| What is Charting by Exception? | document when something out of ordinary, saves time, easy to track unexpected changes, avoids repetition, decr doc time |
| What is a case management? | model of delivering care that includes a multidisciplinary approach |
| What are critical pathways/care maps? | used to direct and monitor pxt care |
| What is a variance? | pxt outcomes that deviate from the plan of care. |
| What is in a problem oriented record? | organize by pxt problems. Incl: database,problem list,initial care plan, discharge summary, progress notes |
| what is acuity recording? | system to determine hours of care for nursing unit |
Created by:
palmerag
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