Chapter 5-Information Technology

Question 1

Elements of documentation

Answer 1

Factual: can be subjective and objective.

Accurate and concise: document facts and information precisely without any interpretations.

Complete and current: document information that is comprehensive and timely. Never pre-chart.

Organized: communicate information and a logical sequence.

Question 2

Legal guidelines

Answer 2

Day in time, legible, non-erasable black ink, no blank spaces.

Don’t use correction fluid, erase, scratch out, or black and out errors. Follow facility procedure for corrections.

Sign all documentation with name and title.

Documentation should be factual not personal opinions or criticism.

Question 3

Documentation formats

Answer 3

Flow charts: shows trends

Narrative documentation: records info as sequence of events

Charting by exception: documents any deviations from the norm

Problem oriented medical records: organized by problem or diagnosis. Examples: SOAP, PIE, DAR.

Electronic health records: replacing manual formats

Question 4

Reporting formats

Answer 4

Change of shift report

Telephone reports (common with transfers)

Telephone or verbal prescriptions

Transfer or handoff reports

Incident reports (unusual occurrences)

Question 5

Telephone prescriptions

Answer 5

1. Have a second nurse listen to the prescription
2. Repeat it back making sure to include the medication‘s name, dosage, time, route.
3. Question anything that seems inappropriate
4. Make sure provider signs the prescription in person within 24 hours

Question 6

Incident reports

Answer 6

Do not put into a clients chart

Examples of occurrences that require an incident report are medication errors, falls, omission of prescription, and needle sticks.

Question 7

Information security (Privacy Rule)

Promotes the use of standard methods of maintaining the privacy of protected health information (PHI) among health care agencies.

*part of HIPAA

Answer 7

• only team members directly responsible for clients care accessing record
• clients have the right to obtain a copy of their medical record
• nurses cannot photocopy any part of a medical record except for documents between facilities and providers
• Medical records must be kept in a secure area
• Electronic records are password-protected
• nurses must not disclose clients info to unauthorized individuals or family members (many hospitals use a code system)
• Communication about a client should only take place in private settings where people can’t overhear
• Follow policies and procedures to monitor staff adherence, protocols, computer privacy, data safety

Question 8

Information security protocols

Answer 8

Log off from computer before leaving the workstation

Never share user ID or password

Never leave a medical record or other printed PHI where others can access it

Shred any printed or written client info after use.

Question 9

SOAP

Answer 9

S: subjective data
O: Objective data
A: assessment
P: plan

Question 10

PIE

Answer 10

P: problem
I: intervention
E: evaluation

Question 11

DAR

Answer 11

D: data
A: action
R: response