DocumentationStu

DocumentationStu - N 336 Documenting and Repor ting...

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Unformatted text preview: N 336 Documenting and Repor ting Documentation The act of recording client care in wr itten for m Creating a wr itt en record of client care Amer ican Nurses Association (ANA) Documentation must be syst ematic, continuous, accessible, communicated, recorded & readily available to all members of the healthcare t eam Nursing Documentation Accurate Comprehensive Flexible to retr ieve cr itical data Maintain continuity of care Track client outcomes Ref lect cur rent standards of nursing practice Confidentiality Legally and ethically obligat ed to keep infor mation about clients confidential Responsible for prot ecting clients record from unauthor ized readers Clients have r ight t o read/obtain copy of their own record HI PPA Health I nsurance Por tability & Accountability Act Legislation protects clients pr ivacy for health infor mation HCP required to provide clients with greater control over personal healthcare infor mation Providers are reqd to notify clients of their pr ivacy policy & make reasonable effor ts to get wr itten acknowledgment Calls for establishment of electronic client records system & pr ivacy r ules to legally protect personal health infor mation (PHI ) Accreditation & Reimbursement The Joint Commission (TJC) specifies guidelines/standards for documentation All clients must have thorough assessment Requires doc within nursing process Requires evidence of client/family teaching and discharge planning Stresses impor tance of evaluating clients outcomes & response to treatment Expects multidisciplinar y care plan I ncludes collaborative approach to pain mgt Multidisciplinar y Communication Contents of M R/Char t Client info & demographic data I nfor med consent Admission nsg hx Nsg dx & plan of care Record nsg care, tx & evaluation Medical hx & dx Contents of M R/Char t Therapeutic orders Progress notes Repor ts of exams & diagnostic studies Client education Summar y of operative procedure Discharge plan & summar y Multidisciplinar y Communication Repor ts Oral, wr itten, or audiotaped exchange of infor mation between caregivers Change of shift repor t, telephone repor ts, transfer repor ts & incident repor ts Conferences care, discharge planning & multidisciplinar y Consultations Refer rals Pur pose of the Wr itt en Record Communication between providers Educational tool Legal documentation of care Quality assurance Research Reimbursement Legal Documentation Failing t o record per tinent health or dr ug infor mation Failing t o record nursing actions Failing t o record that meds have been given Failing t o record dr ug reactions or changes in client condition Wr iting illegibly or incomplete Failing t o document a discontinued med Main Documentation Syst ems Source-or iented: Disciplines char t separat ely Var iety of sections Data scatt ered; may lead t o fragmentation Main Documentation Syst ems...
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This note was uploaded on 05/30/2011 for the course NUR 336 taught by Professor Patriciakelly during the Spring '11 term at St. Xavier.

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DocumentationStu - N 336 Documenting and Repor ting...

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