Professional Documents
Culture Documents
1. Mechanical Ventilators
Example:
Basic components:
Telemetry
Arrhythmia monitor
Collect, store, organize, retrieve and manipulate all data r/'t care of critically ill pt
Purpose: organize pt's current and historical data for use by all care providers in
pt. care
Integrate data from bedside devices, ancillary dept, medications, orders, PA
Incorporate personal computers
Components:
CHN
Synthesis of nsg practice and public health practice applied to promoting and
preserving the health of populations (ANA, 1980).
Focus: population as a whole
Computer systems targeted toward specific functional needs rather than clinical
care/delivery
Population focused:
Used computers since late 1960's. Focused on regulatory compliance, billing and
statistical reporting.
4 domains of concentrations that directed Management Information Systems
(MIS) for practice:
1. Public health on population and epidemiologic trends
2. Home health
3. Special population ex. mental health
4. Outpatient care preventive care
Home Health
Public Health
Coordinated effort at the local, state and federal levels whose mission is fulfilling
society's interest in assuring conditions in which people can be healthy (Institute
of Medicine/lOM, 2004)
Focus:
1. Healthcare programs
2. Agencies
3. Settings
Community Health Systems in CHS:
Telemedicine
Includes:
Monitoring devices that transmit VS and other critical data (ex. post-surgical)
Remote defibrillator—diagnose and resuscitate homebound pt
Alert systems—homebound pt signal for help in an emergency
Technological media to interact with and educate pts in the home and community
Home consultation
Teaching strategies using information technologies include:
Active learning
Personalization
Individualization
Cooperative learning
Contextual learning
Evaluation strategies
Ambulatory Care
Increased accountability
Need for continuous and documented service improvements
Pressures to control utilization
Protection of confidential information
Introduction
Communication Systems
I. Purposes of Documentation
Professional responsibility
Accountability
Communication
Education
Research
Satisfaction of Legal and Practice standards
Reimbursement
Care providers are responsible and accountable for their own practice and
documentation is part of that accountability.
Did you know that your standards of practice and competencies are linked both
indirectly and directly to your documentation?
The medical record can be used by health care students as a teaching tool.
Nurses are responsible for assessing and documenting that the client has an
understanding of treatment prior to intervention.
Two indicators of the above are Informed Consent and Advance Directives.
Narrative Charting
Source-oriented charting
Problem-oriented charting
PIE charting
Focus charting
Charting by exception
Computerized documentation
Critical pathways
V.a. Kardex
Vertical or horizontal columns for recording dates and times and related
assessment and intervention information.
Client teaching.
Use of special equipment.
IV Therapy.
Used to document:
Client's condition, problems, and complaints.
Interventions.
Client's response to interventions.
Achievement of outcomes.
Includes:
The elements that should be contained in clinical records and abstracted for
studies on the effectiveness and costs of nursing care.
Focuses on:
1. Demographics.
2. Service.
3. Nursing care.
Nursing Diagnoses
Report transfers
Communicate referrals
Obtain client data.
Solve problems
Inform a client's family members regarding a change in client's condition.
Incident Reports
Focus Charting
The holistic emphasis on the patient and his/her priorities including ease in
charting.
DO's:
Do read what other providers have written before providing care and before
charting.
Do time and date all entries.
Do use flow sheet/checklist. Keep information on flow sheet/checklist Current.
Do chart you make as observations.
Do write your own observations and sign over printed name. Sign and initial
every entry.
Do describe patients' behavior.
Do use direct patient quotes when appropriate.
Do be factual and complete. Record exactly what happens to patient and care
given.
Do draw a single line thru an error, mark this entry as "Mistaken" and sign your
name.
Do use next available line to chart.
Do document patient's current status and response to medical care and
treatments.
Do write legibly.
Do use standard chart forms.
DON'T's:
Don't begin charting until you check the name and identifying number on the
patient's chart on each page.
Don't begin charting until you check the name and identifying number on the
patient's chart on each page.
Don't chart procedures or chart in advance.
Don't begin charting until you check the name and identifying number on the
patient's chart on each page.
Don't chart procedures or chart in advance.
Don't clutter notes with repetitive or frequently changing data already charted on
the flow sheet/checklist.
Don't fake or sign an entry for someone else.
DONT change an entry because Someone tell you to.
Don't label a patient or show bias.
Don't try to cover up a mistake or accident by inaccuracy or omission.
Don't "white out' or erase an error.
Don't throw away notes with an error on them.
Don't squeeze in a missed entry or "leave space" for someone else who forgot to
chart.
Don't write in the margin.
Don't use meaningless words and phrases, such as "good day' or "no
complaints"
Don't use notebook, paper or pencil