Fundamentals Of Nursing (Chap 16 Documenting, Reporting, Conferring, And Using Informatics) Health Computing!!

FUNDAMENTALS OF NURSING (CHAP 16 DOCUMENTING,
REPORTING, CONFERRING, AND USING INFORMATICS)
HEALTH COMPUTING!!
Documentation-


Answers written or electronic legal record of all pertinent interactions with the pt
(assessing, diagnosing, planning, implementing, evaluating)
The patient record-


Answers compilation of a patient's health information
Documentation guidelines-


Answers content, timing, format, accountability, confidentiality
Content-


Answers enter information in a complete, accurate, concise, current, and factual
manner
Timing-


Answers document in a timely manner. Follow agency policy regarding the
frequency of documentation and modify this if changes in the pts status warrant
more frequent documentation
Format-


Answers check to make sure you have the correct chart before writing, draw a
single line through blank spaces, date and time each entry
Accountability-

, Answers sign your first initial, last name, and title to each entry. don't use dittos,
erasures, or correcting fluids,
Confidentiality-


Answers pts have a moral and legal right to expect that the information contained
in their pt health record will be kept private
Types of breach-


Answers computers, copiers, cordless & cell phones, fax machines, voice pagers
Hippa legislation includes-


Answers punishments for anyone caught violating patient privacy. Those who do
so for financial gain can be fined as much as $250,000 or go to jail for as long as
10 yrs
The ANA states that the most important purpose for pt records is-


Answers communicating within the health care team and providing info. for other
professionals, primarily for individuals and groups involved with accreditation,
counseling, legal, regulatory and legislative, reimbursement, research, and quality
activities
Read back-


Answers the recipient reads back the message as he/she heard and interpreted it
Electronic Health Records (EHR's)-