The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation. Assessment Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight. Data may come from the patient directly or from primary caregivers who may or may not be direct relation family members. Friends can play a role in data collection. Electronic health records may populate data and assist in assessment. Critical thinking skills are essential to assessment, thus the need for concept-based curriculum changes. Diagnosis The formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of patient care. The North American Nursing Diagnosis Association (NANDA) provides nurses with an up-to-date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family, or community. A nursing diagnosis encompasses Maslow's Hierarchy of Needs and helps to prioritize and plan care based on patient-centered outcomes. In 1943, Abraham Maslow developed a hierarchy based on basic fundamental needs innate to all individuals. Basic physiological needs/goals must be met before higher needs/goals can be achieved such as self-esteem and self-actualization. Physiological and safety needs provide the basis for the implementation of nursing care and nursing interventions. Thus, they are at the base of Maslow's pyramid, laying the foundation for physical and emotional health. Maslow's Hierarchy of Needs
Planning The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. Goals should be:
Implementation Implementation is the step that involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. This phase requires nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect care, medication administration, standard treatment protocols, and EDP standards. Evaluation This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data. QuestionAnswer Abbreviation List Includes medical staff-approved abreviations and symbols and their meanings that can be documented in patient records Addendum Amending a patient record entry to clarify or add additional information about previous documentation or to enter late entry Administrative Data Demographic, socioeconomic, and financial information Age of Consent State-mandated age of emancipation Age of Majority age of consent Alternate Care Facilities Provides behavorial health, home health, hospice, outpatient, skilled nursing, and other forms of care Alterate Storage Method System for locating storage for patient records other than at the health care facility such as off-site storage, microfilm, or optical imaging Amending Patient records Correction of an incorrect patient record entry by the author of the original entry Archived Records Records that are placed in storage and rarely accessed, aka inactive records Assessment(A) Portion of the POR progress note that documents judgment, opinion, or evaluation made by the health care provider ASTM E 1762-Standard Guide for Authentication of Healthcare Information Document intended to complement standards developed by other organizations and define a document structure for use by electronic signature process, minimum requirements for different use with electronic signature mechanisms, acceptable electronic signatur Audit Trail List of all changes made to patient documentation in an electronic health record system, including all transactions and activities, date, time, and user who performed the transaction Authentication A patient record entry signed by the author Auto-authentication Authentication of a dictated report by a provider prior to its transcription Automated record system Provides timely access to health information for health surveillance, resource planning, and health care delivery; it replaces paper-based records character Lowercase and uppercase letters, numeric, digits, and special characters Chart Deficiencies Missing reports, documentation, and signatures as determined upon patient record analysis Chronological Date Order Oldest information is filed first in a section of a discharged patient record Clinical Data health information obtained throughout treatment and care of patient Clinical data repository allows for the collection of all clinical data in one centralized database and provides easy access to data in electronic ot printed form to the patient's clinical history COmputer STored Ambulatory Record (COSTAR) outpatient electronic health record system created at Massachusetts general Hospital in the 1960s with the goal of improving the availability and organization of outpatient records Countersignature Authentication performed by an individual in addition to the signature by the original author of an entry Database documentation in the POR of a minimum set of data collected on every patient, such as chief complaint; present conditions and diagnoses; social datal past, personal medical and social history; review of systemsl physical examination; and baseline laborato deficiency slip Form or software completed by the health information analysis clerk and attached to the patient record, which is used to record or enter chart defiencies that are noted in the patient's record delinquent record record that remains incomplete 30 days after patient discharge deliquent record rate Statistic calculated by dividing total number of delinquent records by the number of discharges in the period demographic data Patient identification information collected according to facility policy that includes the patient's name and other information, such as date of birth,place of birth, mother's maiden name, and social security number Dianostic managment plans category of POR's initial plan that documents the patient's condition and management of the condition Digital archive storage solution that consolidates electronic records on a computer server for management and retrieval Digital Signature Type of electronic signature that uses public key cryptography Document Imaging Provides an alternative to traditional microfilm or remote storage systems because patient records are converted to an electronic image and saved on storage media; aka optical dick imaging Electronic Health Record (EHR) aka computer based patient record. automated record system that contains a collection of information documented by a number of providers at different facilities regarding one patient Electronic Medical Record (EMR) automated record system that documents patient care using a computer with a keyboard, mouse, opitcal pen device, voice recognition system, scanner, or touch screen Electronic Signature encompasses all technology options available that can be used to authenticate a document Field group of characters File collection of related records Hospital Ambulatory care record aka hospital outpatient record; documents services received by a patient who has not been admitted to the hospital overnight, and includes ancillary services, emergency department services, and outpatient surgery Hospital Inpatient record documents the care and treatment recieved by a patient admitted to the hospital Hospital Outpatient Record documents services received by a patient who has not been admitted to the hospital overnight, and includes ancillary services, emergency department services, and outpatient surgery Inactive Records aka archived records; Records that are placed in storage and rarely accessed Incident Records collects information about a potentially compensable event (PCE) Independent database contains clinical information created by researchers Indexed identification of scanned pages according to a unique idnetification number making it unnecessary to scan documents for the same patient at the time Information capture Process of recording representations of human thought, perceptions, or actions in documenting patient care, as well as device-generated information that is gathered and/or computed about a patient as part of health care Initial plan Documentation in the POR that describes actions that will be taken to learn more about a patient's condition and to treat and educate the patient according to three categories: diagnostic/management plans, therapeutic plans, and patient eduaction plans integrated record Patient record format that usually arranges reports in strict chronological date order jukeboxes Storage for large numbers of optical disks, resulting in huge storage capabilities longitudinal patient record records from different episodes of care, providers, and facilities, that are linked to form a view, over time, of a patient's health care encounters magnetic degaussing Destruction of electronic records by altering fields on a computer medium manual Record maintenance of patient records in paper format mHealth refers to the use of wireless technology to enable health care professionals to make better-quality decisons while reducing the cost of care and improving convenience to caregivers microfilm photographic process that records the original paper record on film, while the film image appearing similar to a photograph negative nursing assessment documents patient's history, cuttent medications, and vital signs on a variety of nursing forms, including nurses notes and graphic charts objective(O) portion of the POR progress note that documents observations about the patient, such as physical findings or lab or X-ray results off-site storage location separate fromthe facility used to store records, aka remote storage optical disk imaging provides an alternative to traditional microfilm or remote storage systems because patient records are converted to an electronic image ans saved on storage media; aka document imaging patient education plans category of POR's initial plan that documents patient teaching about conditions and treatments patient record Serves as the business record for a patient encounter, contains documentation of all health care services provided to a patient, and is a repsoitory of information that includes demographic data, and documentation to support diagnoses, justify treatment, patient's representative person eho had leagal responsibility for the patient and signs an admission consent form to document consent to treatment physician office record documents the patient health care servics received in a physican's office plan (P) portion of the POR progress note that documents diagnostic, therapeutic and eduacational plans to resolve the problems potentially compensable event (PCE) an accident of medical error that results in personal injury or loss of property preadmission testing (PAT) incorporates patient registration, testing, and other services into one visit prior to inpatient admission with the results incorporated into the patient's record primary sources records that document patient care provided by health care professionals and include original patient record, X-rays, scans, EKGs and other documents of clinical findings problem list documentation in the POR that acts as a table of contents for the patient record because it is filed at the beginning og the record and contains a list of the patient's problems problem oriented medical record (POMR) aka problem oriented record; systematic method of documentation, which consists of four components: database, problem list, initial plan,and progress notes problem oriented record (POR) systematic method of documentation, which consists of four components: database, problem list, initial plan,and progress notes provisional diagnosis working, tentative, admission, and preliminary diagnosis obtained from the attending physican; it is the diagnosis upon which the inpatient care is initially based public key cryptography attaches an alphanumeric number to a document that is unique to the document and to the person signing the document purge remove inactive paper-based records from a file system for the purpose of converting them to microfilm or optical dick or destroying them record collection of related fields record distruction methods paper records are usually disolved in acid , incinerated(burned), pulped or pulverized (crushing into powder), or shredded record linkage aka longitudinal patient record;records from different episodes of care, providers, and facilities, that are linked to form a view, over time, of a patient's health care encounters record retention schedule outlines patient information that will be maintained, time period for retention, and manner in which information will be stored remote storage aka off-site storage;location separate fromthe facility used to store records report generation consists of formatting and/or structuring captured information retention period length of time a facility will maintain an archived record, based on federal and state laws reverse chronological date order most current document is filed first in a section of inpatient record scanner used to capture paper record images onto the storage media and allows for rapid automated retrieval of records secondary sources patient information contai data abstracted from primary sources of patient information such as indexes and registers, committee minutes, and incident reports sectionalized record each source of data in the inpatient record has a section that is labeled shadow record paper record that contains copies od original records and is maintained separately from the primary record signature legend document maintained by the health informations department to identify the author by full signature when initals are used to authenticate entries signature stamp when authorized for use in a facility, the provider whose signature the stamp represents mish sign a statement that the provider alone will use the stamp to authenticat documents solo practitioner aka solo physican practice; do not have physican partners or employment affiliations with other practice organizations source oriented record (SOR) traditonal patient record format that maintains reports according to source of documentation statue of limitations refers to the time period after which a lawsuit cannot be filed subjective(S) portion of the POR progress note that documents the patient's statement about how they feel, including symptomatic information telephone order (T.O.) a verbal order taken over the telephone by a qualified professional from a physican therapeutic plans category of POR's initial plan that specifies medications, goals, procedures, therapies, and treatments used to care for the patient transfer note documented when a patient is being transferred to anothe facility voice order (V.O.) physician dictates an order in the presence of a responsible person; this is no longer accepted as standard practice by health care facilities and is documented in emergencies onlyWhich classification system was developed by the World Health Organization who and used to collect data for statistical purposes?International Statistical Classification of Diseases and Related Health Problems (ICD)
Which is a primary purpose of the patient record?A primary patient record is used by health care professionals while providing patient care services to review patient data or document their own observations, actions, or instructions.
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Which is a systematic method of documentation that consists of four components
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