RNSG 1363 CDM Exam 2 Study Guide Clinical Decision-Making in Evidence-Based Practice Exam 2 Study Guide

DOCUMENTATION o Reasons for Documentation: ▪ Keep a record of the nursing care performed on patients. ▪ Others will know what we did. ▪ Helps tend to research. ▪ Healthcare workers have access to health records. ▪ Make statements about baseline data changing. o Effective Documentation Characteristics: ▪ Consistent with professional and agency standards. ▪ Complete. ▪ Accurate. ▪ Concise. ▪ Factual. ▪ Organized and timely. ▪ Legally prudent. ▪ Confidential. o Confidentiality: ▪ Identifying factors. ⟶ Name, address, SSN. ▪ Diagnosis. o Breaches in Confidentiality: ▪ Leaving paperwork, and clipboard unattended. ▪ Having documentation screened on around others not involved in the plan ofcare. Page 1 of 21 lOMoARcPSD| ▪ Not shredding papers and putting them in the trash. ▪ Giving out information over the phone (unless with physician or persons directly involved in care). ▪ Faxing/emailing information to unauthorized persons. o Methods of Documentation: ▪ Source-Oriented Records: ⟶ Paper format, in which each health care member involved in care keeps data on their separate form. ⟶ Sections of the record are designated for nurses, health care providers, lab, x-ray personnel, etc. ⟶ Notations entered chronological, most. Recent entry nearest the frontof record. Page 2 of 21 lOMoARcPSD| ⟶ Progress Notes: Notes written to inform caregivers of theprogress a patient making toward achieving expected outcomes. ⟶ Narrative Notes: The type of progress n is written by nurses in a source-oriented record add that rdressesroutine care, normal findings,and patient problems identified in the care plan. ⟶ ADVANTAGE: Each discipline can easily find and chart pertinentdata. ⟶ DISADVANTAGE: Data are fragmented, which makes it difficult totrack problems chronologically with input from different groups of professionals. ▪ Problem-Oriented Medical Records: ⟶ Paper records focused on a patient’s problems rather than onsources of information. ⟶ All healthcare workers record information on the same forms. ⟶ SOAP format (Subjective, Objective, Assessment, Plan) is used to organize entries in progress notes of POMR. Caregivers select numbered problems from master list then “SOAP it” on progress sheet. ⟶ ADVANTAGE: Entire health care team works together in identifying a master list of patient problems and contributes collaboratively to care plan. ▪ PIE Charting: ⟶ Unique way of charting that does NOT develop separate care plan. ⟶ Care plan is incorporated into progress notes. ⟶ PROBLEM, INTERVENTION, EVALUATION format (evaluated eachshift). ⟶ ADVANTAGE: Promotion of continuity of care. ⟶ DISADVANTAGE: Nurses need to read all nursing notes to determine problems and planned interventions before initiating care. Page 3 of 21 lOMoARcPSD| ▪ Focus Charting: ⟶ Brings focus of care back to patient and their concerns. ⟶ Focus may be patient need, strength, or problem. ⟶ DAR format: Data—Action—Response. ⟶ ADVANTAGE: Holistic emphasis on the patient and patient priorities. ⟶ DISADVANTAGE: Some nurses report that the DAR categories areartificial and not helpful when documenting care. ▪ Charting by Exception: Page 4 of 21 lOMoARcPSD| ⟶ Shorthand documentation method that makes use of well-defined standards of practice. ⟶ Only significant findings or “exceptions to these standards are documented in narrative notes. ⟶ ADVANTAGE: Less time needed for charting, greater emphasis and easy retrieval on significant data, timely bedside charting, standardized assessment, greater interdisciplinary communication, better tracking of important patient responses,and lower costs. ⟶ DISADVANTAGES: Limited usefulness when trying to prove thathigh-quality safe care was given if a negligence claim is made against nursing. ▪ Case Management Model: ⟶ Promotes collaboration, communication, and teamwork amongst caregivers. ⟶ Makes efficient use of time. ⟶ Increases quality by focusing care on carefully developed outcomes. ⟶ DISADVANTAGE: Works best for “typical” patients with few individualized needs. ⟶ Collaborative (Critical) Pathways are care maps used in case management model. Specifies care plan linked to expected outcomes along a timeline. CBE is frequently used with collaborative pathway documentation systems. ⟶ Occurrence (Variance) Charting: Documentation that occurs whena patient fails to meet an expected outcome, or a planned intervention is not implemented in the case management model. Unexpected event, cause of event, actions taken place in responseof event, and discharge planning are formatted in occurrence charting. Page 5 of 21 lOMoARcPSD| ▪ Computerized Documentation/EHRs: ⟶ Data can be distributed among caregivers in a standardized format, allowing them to compare and uniformly evaluate patientprogress easily. ⟶ Aids in comparing the progress of groups of patients with similar diagnoses. • Results contribute to practice, education, and better nursing practice. ⟶ Personal Health Records (PHRs): Records a patient utilizes to manage their health care. Includes medical history, diagnoses, symptoms, and medications. Includes Standalone PHRs (Patient fills in information from their own records) and Page 6 of 21 lOMoARcPSD| Tethered/Connected PHRs (PHR is linked to specific healthcare organization’s EHR system; patient accesses own health recordsthrough secure portal). ADPIE • Assessment: Systematic and continuous collection, analysis, validation, and communication of patient data. Nurse identifies cues and makes inferences, clusters related data and identifies patterns, and reports/records data. o Initial assessment: ▪ Assessment that is done right after patient is admitted. ▪ Purpose is to establish a complete database for problem identification and planning. ▪ Most institutions have policies that specify a time interval for this assessment to be completed. ▪ CONSISTS OF GETTING PATIENT’S MEDICAL HISTORY AND PERFORMINGPHYSICAL EXAM. o Focused assessment: ▪ Nurse gathers data about a specific problem that has already been identified. ▪ Targets the specific body system where patient demonstrates a problem, disorder, or concern. ▪ Questions to ask include: ⟶ What are your signs and symptoms? ⟶ When did they start? ⟶ Were you doing anything different than usual when they started? ⟶ What makes symptoms worse? Better? ⟶ Are you taking any remedies (medical or natural) for your symptoms? ▪ Assessment may be done during initial assessment if patient’s health problems surface, but is routinely part of ongoing data collection. Page 7 of 21 lOMoARcPSD| ▪ Identify new/overlooked problems. ▪ EXAMPLE INCLUDES NURSE ASSESSING PATIENT THAT CAME IN FORABDOMINAL PAIN. o Emergent assessment: ▪ Patient presents with physiologic or psychological crisis. ▪ Nurse performs emergent assessment to identify life-threatening problems. ⟶ EXAMPLE INCLUDES LONG TERM CARE FACILITY RESIDENT WHOBEGINS CHOKING IN THE DINING ROOM. ⟶ BLEEDING PATIENT BROUGHT TO EMERGENCY DEPT WITH STABWOUND. ⟶ UNRESPONSIVE PATIENT IN REHAB UNIT.