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 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)-
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller IANWAZASKISTUVIA. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $9.99. You're not tied to anything after your purchase.
