Chapter 13 Documentation and Informatics Copyright 2011 Delmar

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Chapter 13 Documentation and Informatics Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Chapter 13 Documentation and Informatics Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Informatics • Clinical information systems • Electronic health record • Nursing information systems Copyright

Informatics • Clinical information systems • Electronic health record • Nursing information systems Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Documentation as Communication • Documentation – Written evidence of: • Interactions • Administration of

Documentation as Communication • Documentation – Written evidence of: • Interactions • Administration of tests, therapies, and education • Client’s responses Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Purposes of Health Care Documentation • • Communication Education Research Reimbursement (continued) Copyright ©

Purposes of Health Care Documentation • • Communication Education Research Reimbursement (continued) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Purposes of Health Care Documentation • Legal and practice standards – – – HIPAA

Purposes of Health Care Documentation • Legal and practice standards – – – HIPAA Informed consent Advance directives ANA standards of care State nurse practice acts The Joint Commission Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Principles of Effective Documentation • Nursing notes must: – – Be logical Be focused

Principles of Effective Documentation • Nursing notes must: – – Be logical Be focused Be relevant to care Represent each phase of nursing process Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Elements of Effective Documentation • • Use of common vocabulary Legibility Abbreviations and symbols

Elements of Effective Documentation • • Use of common vocabulary Legibility Abbreviations and symbols Organization Accuracy Documenting medication error Confidentiality Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Methods of Documentation • Narrative charting • Source-oriented charting • Problem-oriented charting • PIE

Methods of Documentation • Narrative charting • Source-oriented charting • Problem-oriented charting • PIE charting • Focus charting • Charting by exception • Computerized documentation • Case management process Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Forms for Recording Data • • Kardex Flow sheet Nurse’s progress notes Discharge summary

Forms for Recording Data • • Kardex Flow sheet Nurse’s progress notes Discharge summary Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Reporting • Summary reports • Telephone reports and orders • Incident reports Copyright ©

Reporting • Summary reports • Telephone reports and orders • Incident reports Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Computers in Nursing • Professional nurse as information consumer and producer • Informatics competencies

Computers in Nursing • Professional nurse as information consumer and producer • Informatics competencies for nurses • Applications of nursing informatics • Telehealth (continued) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Computers in Nursing • Evidence-based practice and research • Criteria for evaluating validity of

Computers in Nursing • Evidence-based practice and research • Criteria for evaluating validity of information Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

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