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Patient Care Management: Reports and Records, Authentication: Methods…
Patient Care Management: Reports and Records
Nursing Documentation
It is the total written information by nurses concerning a patient's health status, needs, care, and response to care. It's a fundamental skill for clear communication among the healthcare team and provides a full account of patient care.
Record
An administrative tool used to classify information and prevent duplication. Record keeping is the proper recording and maintenance of facts, events, or history in writing or electronic form.
Report
A verbal or written communication about a patient's health status, needs, treatments, outcomes, and responses.
Principles of Good Documentation and Reporting
Fact
Accuracy
Completeness
Currentness
Clarity
Legibility
Organization
Confidentiality
Importance of Nursing Documentation (Benefits)
It serves as a means of communication
documentary evidence of illness/treatment
a basis for quality analysis/auditing
provides clinical data for research/education
aids in planning individual patient care
protects legal interests of all involved parties
ensures continuity of care
Key Components of Nursing Documentation
Assessment of patient health status
Identified patient needs and/or nursing diagnoses
Planned care and revision of planned care
Nursing interventions
Patient teaching, patient outcomes
Interdisciplinary communication
Reports
Written Reports
Shift Report
Incident Report (Occurrence Variance Report - OVR)
Report of Complaint
Report for Requisition
Report of Negligence
Oral Reports Given when information is needed immediately, not for permanency. Examples include oral shift reports and reports to a physician or supervisor about a patient's condition.
Classification of Records
A. Nursing Unit Records
These are records kept in the patient unit:
Patient Record
Assignment Record
Time Record (Time-schedule record)
Patient Census Record
Inventory Record:
Nursing Office Records
Personnel Record: Consists of employment and evaluation records for each nurse.
Employment Record
Evaluation Record
Master Record of Nursing Hours:
A record in the nursing office indicating the distribution of hours for each category of nursing staff across the hospital to assess coverage adequacy.
Elements of Electronic Nursing Documentation
Accessibility: Ease with which information can be accessed or extracted.
Flexibility: The system adapts to the changing demands of users and can be upgraded.
Integration: The system allows data from various sources (monitors, labs, imaging) to be incorporated directly.
Timeliness: Provides timely responses, offers up-to-date information, and allows easy addition/retrieval of data.
Ease of Use: The system is developed without being heavy or requiring multiple/complex steps.
System Security: Protection of information from unauthorized access, modification, or destruction.
Authentication: Methods (like passwords) to verify user identity.
Authorization: Access controls or other means to provide specific information to a given user.