Chapter 04 Jarvis summary PDF

Preview

Summary

Chapter 5 summary of Jarvis 3rd edition The Complete Health History...

Description

Perry et al.: Canadian Clinical Nursing Skills & Techniques, 1st Edition Chapter 04: Documentation and Informatics Printable Key Points • The electronic (or paper-based) medical record is a legal document that contains information describing the care delivered to a patient. • A nurse’s documentation provides a detailed account of a patient’s plan of care, assessment, and treatment, which must be an accurate and timely evaluation of information. • Documentation provides continuity of care and evaluates patient outcomes. • All information contained in the medical record is confidential; all members of the health care team are legally and ethically obligated to keep patient information confidential and to adhere to documentation standards. • A patient’s record or chart is a confidential, permanent legal document containing information relevant to a patient’s health care. Nurses and other health care providers record information about a patient’s health care after each patient contact. The record is a continuing account of the patient’s health status and needs, treatments delivered, results of diagnostic tests, and response to therapy. • Reports are oral or written exchanges of information among caregivers; they include information about a patient’s clinical status, observations made about the patient’s behaviour, data pertaining to diagnostic tests, and directions for changes in therapy. • EHRs are part of evidence-informed practice, allowing improvement in both clinical decisionmaking and patient outcomes; chronic disease can also be managed more effectively through EHRs. • Quality documentation must be factual, accurate, complete, current, and organized. • Common record-keeping forms are admission nursing history, flow sheets or graphic records, patient education record, patient care summary or Kardex, acuity records, standardized care plans, and discharge summaries. • Common communication and documentation errors include (1) failing to document the correct time of events, (2) failing to record verbal prescriptions or have them signed, (3) charting actions in advance to save time, (4) documenting incorrect data, and (5) failing to give a report or giving an incomplete report to an oncoming shift. Nurses must be aware of the legal guidelines for documentation and reporting. • Charting systems include narrative documentation, problem-oriented, patient database, problem list, plan of care, progress notes, source records, charting by exception, and critical pathways. • Narrative notes, SBAR, SOAP, PIE, and Focus or DAR charting formats organize entries in the progress notes according to the nursing process. • Hand-off occurs during shift change or any time the patient changes caregivers. During a handoff communication process that patient and patient information are transferred to the next caregiver. Hand-off is also used across the health care continuum when patients leave one health system for another. • Hand-off reports provide continuity of care, and are given face-to-face, through a written report, with the EHR, or during bedside rounds.

Copyright © 2020, Elsevier Inc. All rights reserved.

4-2

Key Points

• Adverse events should be reported and documented whether an injury occurred or not; AERs are an important aspect of quality improvement. • An important component of care transitions is the process of medication reconciliation, which is the assessment of the patient’s current medications compared to medications actually prescribed at a care transition point. This process minimizes medication errors and adverse events. • Long-term care documentation is interdisciplinary; the overall goal is a system of clinical documentation that identifies potential or actual problems and provides improved actions for each problem, which results in improved care for residents.

Copyright © 2020, Elsevier Inc. All rights reserved....