Đang chuẩn bị liên kết để tải về tài liệu:
Lecture Nursing documentation using electronic health records: Chapter 2 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 2 - Nursing documentation overview. After completing Chapter 2, the students will be able to: Describe the role of documentation in nursing practice; identify the purposes of documentation; identify and explain different types of documentation methods; explain documentation of medication administration using an electronic Medication Administration Record (eMAR); explain the importance and relevance of nursing diagnoses, NOC, and NIC in nursing documentation. | Chapter 2 Nursing Documentation Overview © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 2 Content 2.1 Role of documentation in nursing practice 2.2 Purposes of documentation 2.3 Documentation methods 2.4 Medication administration using an electronic Medication Administration Record (eMAR) 2.5 Nursing diagnoses, NOC, and NIC LO 2.1 Role of Documentation in Nursing Practice LO 2.1 Role of Documentation in Nursing Practice Communication Key to preventing medical errors Promoted by documentation by all disciplines Assessments Treatments Diagnostic testing Preparation for discharge Trend toward use of EHR to enhance communication LO 2.1 Role of Documentation in Nursing Practice Advantages of EHRs Enhanced quality of documentation Promotion of safe, effective patient care Readily accessible information Elimination of illegible handwriting Automatic alerts Decision support Reduction in duplication of diagnostic testing LO 2.1 Role of Documentation in . | Chapter 2 Nursing Documentation Overview © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 2 Content 2.1 Role of documentation in nursing practice 2.2 Purposes of documentation 2.3 Documentation methods 2.4 Medication administration using an electronic Medication Administration Record (eMAR) 2.5 Nursing diagnoses, NOC, and NIC LO 2.1 Role of Documentation in Nursing Practice LO 2.1 Role of Documentation in Nursing Practice Communication Key to preventing medical errors Promoted by documentation by all disciplines Assessments Treatments Diagnostic testing Preparation for discharge Trend toward use of EHR to enhance communication LO 2.1 Role of Documentation in Nursing Practice Advantages of EHRs Enhanced quality of documentation Promotion of safe, effective patient care Readily accessible information Elimination of illegible handwriting Automatic alerts Decision support Reduction in duplication of diagnostic testing LO 2.1 Role of Documentation in Nursing Practice Concerns with Use of EHRs Confidentiality/HIPAA Power outages Computer “crashes” Computer viruses altering data LO 2.2 Purposes of Documentation LO 2.2.Purposes of Documentation Prevention of medical errors Communication with other healthcare providers Demonstrate the delivery of care Ensure appropriate reimbursement Demonstrate adherence to accreditation standards Provide evidence in legal proceedings Promote knowledge development through research LO 2.2.Purposes of Documentation Three ‘Cs’ of Documentation Comprehensive Concise Clear LO 2.2.Purposes of Documentation Characteristics of Good Documentation Factual Accurate Complete Current Organized Legible Secure LO 2.2.Purposes of Documentation Types of Documentation Errors Errors of omission Inaccurate documentation Incomplete documentation LO 2.3 Documentation Methods LO 2.3 Documentation Methods Documentation Methods Narrative Charting by exception (CBE) Source oriented Focus charting (DAR) Critical pathway / .