1. COMMUNICATION

2. 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

3. 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

4. Legal Issues related to written documentation

5. 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

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

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

8. 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

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

10. Long-term Care Documentation b SEE Kozier page 356

11. HOME CARE DOCUMENTATION b SEE KOZIER 356

12. 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

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

14. 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