PPT-Does Your Nursing Documentation Reflect Everything You Do?

Angie McDonald RN Kentucky Department of Education September 20176 Good Data is Invaluable Good health office visit data can be a school nurses best friend It can show many different things including the number of students being seen what they are being seen for and how many students were sent home. Emit. Emit means to give off or produce (Ex. Giving off light) .  . Reflect. Reflect means to give back or bounce (ex. reflecting light). Make a table. Location. Emit. Light. Reflect Light. What emits and reflects light in the following places?. Chapter 7. The Nursing Process: . Documenting the Nursing Process. Reference. Doenges. , M. E., & . Moorhouse. , M. F. (. 2008). . Application of nursing process and.  . nursing diagnosis: An interactive text for diagnostic reasoning. 1. . No planner, presenter, faculty, authors, or content expert has identified a conflict of interest that would affect the educational activities.. 2. No commercial interest has provided financial or in-kind support for this educational activity. . Patient Documentation. Super User Training. 1. Upon completion of training, the learner will demonstrate ability to: . 1. Share the vision for the changes in nursing documentation. 2. . Identify . reporting. nursing . informatics. Communication is Vital!. Technology is your friend!. Principles of Data Entry. Accurate:. Observations only. Do not use subjective words. Correct spelling, grammar & med terms. Overview of Clinical Terms & Tips for Data Abstraction . MSTCVS Cardiac Surgery Quality Collaborative. Data Manager Meeting. The Inn at St. John’s. March 11. th. , 2016. Melissa Clark, MSN, RN. Patient Documentation. Super User Training. 1. Upon completion of training, the learner will demonstrate ability to: . 1. Share the vision for the changes in nursing documentation. 2. . Identify . Documentation tells a story. Quality documentation tells a story that everyone can understand. What does your documentation say about you? . Financial implications. Documentation is a receipt, warranty and guarantee for payments received.. Case . Examples & . Highlights. When Documentation Gets in The Way of the Defense. Presented By: . Joanne . Gulliford Hoban. Morrison . Mahoney, LLP. Case #1 – Emergency Department . Example of documentation in ED by both MD & RN. Undergraduate . Education . Electronic . Charting . in . Nursing . Education within . Simulation. Veronica D. Feeg PhD, RN, FAAN. Jennifer E. Mannino PhD(c), MS, MA, RN. Geraldine L. Cornell, MS, RN. Heather Wacholz RN, BSN, CCRN-CMC, CNRN. March 3, 2015. Western Carolina university. What is Nursing Informatics. Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Care. An Overview. Training Objectives. NF Documentation and Eligibility. NFLOC Factors. LOC Review & Length of Stay Determination. Transfer / Reintegration. Reconsideration / Appeals / Fair Hearings. Learn how to create nursing care plans, effectively document care, and succeed in the course with Nursing Care Plans: Transitional Patient and Family Centered Care, Sixth Edition . Easy-to-understand and packed with practical tools to prepare you for clinical practice, this proven bookfocuses on the nursing plans that are most important, ensuring that you learn what you need to know and that you can find the information you need easily, without being distracted by irrelevant information. · Maximize your study time with Chapter 1’s step-by-step guidance on how to use the text, including a guide on how to use the book’s icons.· Learn the various considerations to keep in mind when creating nursing care plans through Safety and Quality icons that use a scale of 1-5 to show risk severity and include suggestions for action.· Increase your recall of important information with new, true-to-practice briefer interventions developed by expert clinicians.· See how theory translates into practice with more than 85 sample nursing care plans.· Broaden your knowledge with new care plans for Maternity, Pediatrics, and Mental Health.· See the importance of evidence-based practice through new evidence-based rationales and guidelines.· Experience anytime, anywhere access to day-to-day encounters and special risk information with the Laminated Quick Reference Information Card.· Easily design your own care plans with the Care plan Creator on thePoint.· Master each chapter’s content with Chapter Openers that include background, diagnostic cluster, discharge criteria, and collaborative problems.· Find the information you need fast with a user-friendly format that splits Collaborative Problems and Nursing Diagnosis in each chapter and organizes care plans by Medical Conditions, Surgical Procedures, and Diagnostic and Therapeutic Procedures.· Prepare for effective nursing practice with NIC & NOC cited prior to interventions and helpful author notes that provide advice on how to implement a course of care.Learn best practices with physician-prescribed interventions and relevant documentation in each care plan. Day, Egusquiza, President. AR Systems, Inc . 1. What does “Integrated CDI’ mean- 2 step?. Patient status /UR. coming together with . traditional CDI/coding . to create a coordinated, cohesive effort to ensure documentation in the medical record to support BOTH inpt status or observation PLUS the most complete diagnosis to support correct coding and ICD -10..