Module 6 – Pre - work
Name: MANZANO, Enrico Charles L. Date: 11/17/2020
Section: BSN 1 – K Score:
I. List the measures used to maintain the confidentiality of client records
a. Restrict access
b. Ethical codes and legal responsibility – patient’s record is protected legally
c. Policies and procedures to ensure privacy and confidentiality
II. Discuss reasons for keeping client records
• Communication
Planning client care - progress notes that we plan out the care of the client.
• Auditing health agencies
• Research - use it as for research. Utilize the record of clients. Like for
example, MALE or FEMALE most vulnerable for covid 19.
• Education - case presentations. Don’t use the name of the clients.
Reimbursement – medical care. Looking for PhilHealth.
• Legal documentation – identify the reason why the client is still in pain.
• Health care analysis – we continue to research as evidence for our plan of
care.
III. Identify and discuss guidelines for effective recording that meets legal and ethical standards.
1. Source-Oriented Records - Source-oriented (SO) charting is a
narrative recording by each member (source) of the health care team charts
on separate records. SO charting is time-consuming and can lead to
fragmented care.
2. Problem-oriented Medical Records (POMR) - is a comprehensive approach to
recording and accessing patient medical data. First developed by Lawrence
Weed, MD, in the 1960s, the POMR gathers information from all members of
the patient's care team in order to determine a diagnosis and create a
treatment plan.
3. PIE Documentation - The progress notes in the patient record use (P) to define
the particular Problem; (I) to document Intervention; and (E) to Evaluate the
patient outcome. PIE charting integrates care planning with progress notes.
4. Focus Charting - is a method for organizing health information in the individual's
record. It is a systematic approach to documentation, using nursing
terminology to describe individual's health status and nursing action.
5. Charting by Exception (CBE) - or variance charting is a system for
documenting exceptions to normal illness or disease progression, using a
shorthand method of charting what's usual and normal. You need to make
additional documentation when the patient's condition deviates from the
standard or what's expected.
6. Computerized Documentation - provide for the documentation of patient care
using computers. For example, the CDS records the vital signs directly from the
cardio-respiratory monitors, while other documentation, such as nursing
assessments are entered by the clinician.
Guidelines:
• Date and time should be according to the 24 hour military clock.
• Dark pen must be use (no sign-pen allowed)
• Concise
• Completeness
• In-order
• Legible
• Accurate
• Correct spelling
• Avoid writing the word error
• Follow agency policy
IV. Identify essential guidelines for reporting client data.
Guidelines for reporting client data should be concise including pertinent information
but no extraneous detail.
Types of reporting:
1. Change-of-shift report
2. Telephone reports
3. Telephone and Verbal reports
4. Care plan conference
5. Nursing rounds
6. SBAR
Guidelines for Change-of-shift report:
Basic identifying information should be provided
Follow the particular order
It should be written, orally, face-face-audiotape recording
Concise data
Exact information towards the client must be provided
Guidelines for receiving a telephone report:
Record the name of person giving the information
Repeat information
Record the subject of the information received
The time and date must be recorded
Be concise
Guideline for receiving telephone and verbal orders:
Ask the prescriber to talk slowly and clearly
Know the agent’s policy
Ask prescriber to spell out the medication if unfamiliar
Question the drug, dosage, or changes if seem inappropriate
Use words instead of abbreviations to avoid misunderstanding.
V. Identify prohibited abbreviations, acronyms, and symbols that cannot be used in any form of
clinical documentation.
i. Do not use list:
1. U, u (unit) - Mistaken for “0” (zero), the number “4” (four) or “cc”
2. IU (International Unit) - Mistaken for IV (intravenous) or the number 10 (ten)
3. Q.D. ,QD, q.d. ,qd (daily) - Mistaken for each other
4. Q.O.D., QOD., q.o.d, qod (every other day) - Period after the Q mistaken for "I" and “O”
mistaken for “I”
5. Trailing zero (X.o mg)* - Decimal point is missed
6. Lack of leading zero (.X mg) - Decimal point is missed
7. MSO4 and MgSO4 - Confused for one another
8.
ii. Other may derived from Latin
iii. JCAHO National Patient Safety Goals (2004)
