COMMUNICATION. PURPOSES OF CLIENT RECORDS 1. Communication1. Communication 2. Planning client care2. Planning client care 3. Auditing3. Auditing 4. Research4.

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Presentation transcript:

COMMUNICATION

PURPOSES OF CLIENT RECORDS 1. Communication1. Communication 2. Planning client care2. Planning client care 3. Auditing3. Auditing 4. Research4. Research 5. Education5. Education 6. Reimbursement6. Reimbursement 7. Legal Documentation7. Legal Documentation 8. Health care analysis8. Health care analysis

DOCUMENTATION SYSTEMS b 1. Source-oriented b 2. Problem-Oriented Medical Record b 3. Focus Charting b 4. Charting by Exception b 5. FACT b 6. CORE b 7. Outcome Documentation b 8. Computerized 9. Case management

Legal Issues related to written documentation

DOCUMENTING NSG ACTIVITIES b 1. Admission Nsg Assessment b 2. Flow sheets (4 types +) b 3. Nsg care plan, Kardex, critical pathway, progress notes, problem list b 4. Nsg discharge/Referral Summaries

CHANGE OF SHIFT REPORT TYPES (2) b 1. Focused report b 2. Walking rounds

SHIFT REPORT DATA b SEE deWitt page 30 -table 2-5 b SEE KOZIER page 361

TELEPHONE REPORTS b 1. Repeat information to caller b 2. Document date and time b 3. Document name of person giving information b 4. Document information received b 5. Sign notation

TELEPHONE ORDERS b 1. Identify caller b 2. Repeat info to caller b 3. Transcribe order and indicate TO

Long-term Care Documentation b SEE Kozier page 356

HOME CARE DOCUMENTATION b SEE KOZIER 356

GUIDELINES FOR RECORDING b 1. Date and time b 2. Timing b 3. Legibility b 4. Permanence b 5. Accepted terminology b 6. Correct spelling b 7. Signature 8. Accuracy 9. Sequence

(Con’t) b 10. Appropriateness b 11. Completeness b 12. Conciseness b 13. Legal prudence

COMMUNICATION TECHNIQUES b 1. Communication process b 2. Modes of communication b 3. Factors influencing communication process b 4. Therapeutic communication b 5. Barriers to communication b 6. Nsg process & communication

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