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Documenting reporting nursing informatics. Communication is Vital! Technology is your friend!. Principles of Data Entry. Complete: New or changed information S/S, clients behavior Nursing interventions Meds given Physicians orders carried out Client teaching and response to therapy. - PowerPoint PPT Presentation
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DOCUMENTINGREPORTING
NURSING INFORMATICS
Communication is Vital!Technology is your friend!
PRINCIPLES OF DATA ENTRY
Accurate:Observations onlyDo not use
subjective wordsCorrect spelling,
grammar & med terms
Complete:New or changed
informationS/S, clients
behaviorNursing
interventionsMeds givenPhysicians orders
carried outClient teaching and
response to therapy
PRINCIPLES OF DATA ENTRY Consistent
Concise and brief using approved abbreviations Objective
Important when documenting psychosocial and mental health issues
Legible Writing must be clear and easily read by others Line out errors: 100 cc clear yellow urine from foley
Organization Use nursing process
Timelines Document care, treatments, procedures and
medications as soon as possible
DOCUMENTATION Purpose of documentation:
CommunicationAssessmentCare planningQuality assuranceReimbursementLegal documentationResearchEducation
INFORMATICS Technology in healthcare is advancing Information will be managed
electronically Outcomes:
Safe patient carePatient centered care Improved outcomesEase of access to informationWorkflow
EHR- A STANDARD DOCUMENT THE BEDSIDE CHART HAS MOVED FROM A DESCRIPTIVE DOCUMENT TO A DATA DRIVEN DOCUMENT
Forms use a standardized language Radio buttons, drop-down boxes Data driven Mandatory fields Charting by exception Increases compliance Alerts to abnormal findings Able to document all aspects of nursing
care
TECHNOLOGY WILL YOU ENCOUNTER IN THE HOSPITAL AND CLINICS
EHR/EMR Monitoring Imaging Medication administration Pharmacy Clinical Decision Support
Systems ADT CPOE Central supply ordering systems
HEALTH IT SYSTEMS AND HUMAN ERRORElements that reduce human error: CPOE Bar Code High Alert Medication Documentation Point of Care Documentation Mandatory Fields Smart Pumps Communication Tool
COMMON DOCUMENTS USED BY NURSES
Admission History and Assessment
Discharge Form Nursing Care Plans Flow Sheets/graphic
sheets Kardex
Clinical Pathways Medication
Administration Records (MAR)
Nursing Progress Notes
Patient education form
Acuity charting Incident report
Does NOT go in pt chart!
VITAL SIGNS
MAR
ASSESSMENT FORM
PATIENT SUMMARY SCREEN
ORDERS SCREEN
MEDICATION ADMINISTRATION
OTHER TECHNOLOGY
REMEMBER:
HIPAA
CHANGE OF SHIFT REPORTPurpose TechniquesContent
SBARSituation Pt name Age Physician’s name Diagnois Hospital day/POD
#
Background
What brought them to the hospital
Past medical history
SBARSituation BackgroundAssessment Recommendation/ Request Often a framework for communication-
calling MD, giving report, etc
SBARAssessment State what you think
is the problem Give review of
symptoms
Recommendation or Request
What needs to be done
What was done Plan for discharge
TYPES OF NURSING NOTES- NARRATIVE Information written in sentences or
phrases usually time sequenced
Must write a narrative note q2 hrs
Many combined with flow sheets
TYPES OF NURSING NOTES- CHARTING BY EXCEPTION Document only findings that fall outside
of “normal” Flow sheet with check boxes Assessment findings, routine care
activities Narrative notes only when there is an
exception or abnormal finding Eliminates redundancy