10662339
Description
Flashcards by Alexandra Bozan, updated more than 1 year ago
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Created by Alexandra Bozan
about 7 years ago
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| Question | Answer |
| 3 methods of communication central to the nurse's professional role: | documenting, reporting and conferring |
| HIPAA | Health Insurance Portability & Accountability Act, protects the privacy of individually identifiable health information |
| Write a progress note for each of these instances | 1. Upon admission, transfer to another unit, and discharge 2. When a procedure is performed 3. Upon receiving a patient post-operatively or post-procedure 4. Upon communicating w/physician regarding critical patient info (i.e. abnormal lab value) 5. For any change in patient status |
| Under HIPAA, patients have a right to | 1. see/copy/update their health record 2. get a list of the disclosures 3. request a restriction on certain uses or disclosures 4. choose how to receive health info |
| read back | The recipient reads back the message as they heard and interpreted it. the person giving the order confirms interpretation of the order is correct |
| the RN who receives the order will | 1. record the order in the patient's medical records 2. read back the order 3. note date/time the orders were issued 4. Record VOs (verbal orders), physician or nurse practitioner who issued orders, followed by RNs initials/title |
| the physician who issed the VO | 1. reviews the order 2. signs, date/time the order |
| EHR | Electronic Health Record. created when agencies under different ownership share their data |
| EMR | Electronic Medical Record. created by an agency/agencies having common ownership. not true EHR |
| PHR | Personal Health Record. prepared online by patients to manage their health care. |
| two types of PHR | Standalone PHR and Tethered/Connected PHR |
| Standalone PHR | patients fill in info from their own records; info is stored on patient's computer or the internet |
| Tethered/Connected PHR | linked to a specific health care organization's EHR system or a health plan's information system |
| HIE | health information exchange allows doctors, nurses, pharmacists, other care providers, to securely access/share medical info electronically |
| source oriented records | traditional paper records in which each health care group keeps data on its own separate form |
| progress notes | written to inform caregivers of the progress a patient is making toward achieving expected outcomes |
| narrative notes | progress notes written in a source-oriented record, address routine care, normal findings and patient problems identified in the plan of care |
| POMR | problem oriented medical record: organized around the patient's problems rather than around sources of information. all health care professionals record information on the same form. |
| SOAP format | Subjective data, Objective data, Assessment, Plan is used to organize entries in the progress notes of the POMR. originates from the medical record. |
| PIE charting | Problem Intervention Evaluation: it doesn't develop a separate plan of care, it's incorporated into the progress notes. has a nursing origin. assessment performed @ beginning of each shift, problems are numbered and resolved problems dropped |
| focus charting | brings the focus of care back to the patient and their concerns |
| DAR | Data Action Response. used in the narrative portion of focus charting |
| CBE | charting by exception. shorthand documentation method; only significant findings or exceptions are documented in narrative notes. limited usefulness when trying to prove that high-quality safe care was given |
| collaborative pathways (critical pathways) | used in the case management model. specifies the plan of care linked to expected outcomes along a timeline. CBE are frequently used w/this model. |
| occurrence/variance charting | done when a patient fails to meet an expected outcome or a planned intervention is not implemented. document the unexpected event, cause of the event, actions taken in response, and discharge planning (when appropriate) |
| flow sheets | used to record routine aspects of nursing care |
| graphic record | records specific patient variables such as pulse, respiratory rate, bp, temp, weight, fluid intake/output, bowel movements and other patient characteristics |
| acuity records | used to rank patients as high-to-low acuity in relation to both the patient's condition and need for nursing assistance or interventions. often used to determine staffing requirements |
| OASIS | Outcome and Assessment Information Set: key component of Medicare's partnership with the home care industry to foster/monitor improved home health care outcomes |
| RAI | Resident Assessment Instrument: documentation in long-term care settings helps staff gather definitive information on a resident's strengths and needs, addressing them in an individualized plan of care |
| RAI consists of 4 basic components | 1. minimum data set 2. triggers 3. resident assessment protocols 4. utilization guidelines |
| ISBAR communication | a framework for communication between members of the health care team about a patient's condition |
| ISBAR | I - identify/introduce: S - Situation B - Background A - assessment R - recommendation |
| ISBAR: I | identify/introduce: communicate who you are, where you are, and why you are communicating |
| ISBAR: S | situation: communicate what is occurring and why the patient is being handed off to another department or unit |
| ISBAR: B | Backgrouund: explain what led up to the current situation and put in context if necessary |
| ISBAR: A | Assessment: give your impression of the problem |
| ISBAR: R | Recommendation: explain what you would do to the problem |
| ISBARR | Last R is for read-back of orders/response |
| incident/variance report | document the occurrence of anything out of the ordinary that results in or has he potential to result in harm to a patient, employee or visitor |
| nursing care rounds | procedures in which a group of nurses visit selected patients individually, at each patient's bedside. purpose is to gather information, help plan nursing care, evaluate nursing care patients received and provide them w/an opportunity to discuss their care. patient/family can participate. can make rounds with physicians to share the nursing's perspective |
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