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Documentation & reporting fall 10

Documentation & reporting fall 10 - The patient was...

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The patient was in unusual good health until his airplane ran out of gas and crashed Welcome to charting errors
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Documentation & communication Kimberly Glenn MN,RN,CPN Nursing 312 Foundations
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Objectives Describe multidisciplinary communication within the healthcare team Describe 5 quality guidelines for documentation and reporting Discuss legal guidelines for documentation Identify elements to include on discharge documentation Describe the purpose and content of a change-of- shift report Evaluate the importance of verifying telephone orders
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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.
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Documentation Reporting and recording- types of communication used by health care providers. It is a fundamental tenant of nursing care Why do we document??
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Why?? Communication: plan of care needs to be as clear as possible to anyone who reads it Legal: chart ASAP to maintain clear idea of what happened AND cover your actions Financial billing: detailed recording for reimbursement Education: can explain a patient response Research:
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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.
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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
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Guidelines for Quality Documentation and Reporting Factual: objective & descriptive Accurate: avoid irrelevant info Complete: care provided & response Current: Timely (military time) Organized: logical order Table 26-2 pg 390
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Methods of Documentation TYPE CONCEPTS ADVANT/DISADVANT Narrative Story oriented •A: easy to use •D: doesn’t present in a sequence Problem- oriented Emphasizes client’s problems SOAP; PIE •A: coordinates common plan
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