What is computerized documentation?
Background. Computerized clinical documentation systems (CDS) 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.
What is the purpose of nursing documentation?
Introduction. Nursing documentation is essential for good clinical communication. Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver great care.
What are the basic rules of nursing documentation?
For documentation to support the delivery of safe, high-quality care, it should: Be clear, legible, concise, contemporaneous, progressive and accurate. Include information about assessments, action taken, outcomes, reassessment processes (if necessary), risks, complications and changes.
What is pie charting in nursing?
PIE charting was developed by nurses at the Craven Regional Medical Center to streamline documentation. “PIE” stands for Problem, Intervention, and Evaluation. PIE charting eliminates the need for the traditional nursing care plan because the ongoing plan of care is incorporated into daily documentation.
What are the documentation standards?
Documentation process standards define the process used to produce documents (example here). This means that you set out the procedures involved in document development and the software tools used for document production. Document process quality standards must be flexible and able to cope with all types of documents.
What are the types of nursing documentation?
The documentation in the health system takes place in order to fulfill administrative and clinical purposes, while in the bibliography various nursing documentation types are reported: notes of narrative type, the files which are directed to the problem, the files which are directed to the source, the recording by …
What is the SOAP method of charting?
Today, the SOAP note – an acronym for Subjective, Objective, Assessment, and Plan – is the most common method of documentation used by providers to input notes into patients’ medical records. They allow providers to record and share information in a universal, systematic and easy-to-read format.
What is the job description of an documentation specialist?
Documentation specialists are administrative workers who manage office documents. Their primary responsibilities include organizing an archiving system, retrieving documents upon request and outlining a long-term storage strategy. Completely free trial, no card required.
How long does it take to become a clinical documentation specialist?
Any of these programs will suffice for entry-level work as a clinical documentation specialist. The associate’s degree takes two years to complete, the certificate of achievement takes two to three semesters, and a certificate of competence can be completed in one intense semester.
What is cliclinical documentation?
Clinical documentation professionals use government-sponsored professional coding systems such as ICD-10-CM and CPT to report on patient records, diagnoses, the quality of their care, and any other services provided.