{"id":670,"date":"2024-04-08T21:34:46","date_gmt":"2024-04-09T01:34:46","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/?post_type=chapter&#038;p=670"},"modified":"2024-04-08T21:34:46","modified_gmt":"2024-04-09T01:34:46","slug":"7-4-1-integrated-documentation","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/chapter\/7-4-1-integrated-documentation\/","title":{"raw":"7.4.1 Integrated Documentation","rendered":"7.4.1 Integrated Documentation"},"content":{"raw":"NPs working in LTC may be expected to document. Poor documentation practices in LTC:\r\n<ul>\r\n \t<li>May contribute a delayed response to a change in health status<\/li>\r\n \t<li>May negatively affect a resident's safety, health, and wellbeing<\/li>\r\n \t<li>May negatively affect patient health outcomes<\/li>\r\n \t<li>Contribute to critical incidents<\/li>\r\n<\/ul>\r\nThe Medical Record may include:\r\n<ul>\r\n \t<li>Advance Care Plan<\/li>\r\n \t<li>Medical history<\/li>\r\n \t<li>Medications<\/li>\r\n \t<li>NP\/MD progress notes<\/li>\r\n \t<li>Progress notes by team<\/li>\r\n \t<li>Documented physical exams<\/li>\r\n \t<li>Care plans<\/li>\r\n \t<li>Consult notes from specialist<\/li>\r\n \t<li>Diagnostics \u2013 labs and imaging<\/li>\r\n \t<li>Admission and discharge summaries<\/li>\r\n \t<li>Resident Assessment Instrument (RAI) Assessments<\/li>\r\n \t<li>Comprehensive assessments<\/li>\r\n<\/ul>\r\nEffective documentation facilitates:\r\n<ul>\r\n \t<li>Health care providers having the right patient health information at the right time to guide decision making<\/li>\r\n \t<li>High quality comprehensive care that is resident centered, holistic, and inclusive<\/li>\r\n \t<li>Continuity of care and safe transfers in care amongst rotating staff<\/li>\r\n \t<li>Effective individualized care plans<\/li>\r\n \t<li>Interdisciplinary team mobilization to effectively meet a resident\u2019s needs<\/li>\r\n \t<li>Accurate data to facilitate quality RAI assessments<\/li>\r\n \t<li>Effective infection control practices<\/li>\r\n<\/ul>\r\nLTC National Standards: Individualized Care Plan\r\n<ul>\r\n \t<li>Ongoing documentation of needs<\/li>\r\n \t<li>An accurate problem list that captures active issues and their treatment plans<\/li>\r\n \t<li>Residents\u2019 goals of care, preferred level of medical information, needs, and preferences<\/li>\r\n \t<li>Team members involved in care<\/li>\r\n \t<li>Safety plans \u2013 risk for elopement, substance use, aggression<\/li>\r\n<\/ul>\r\n[footnote]American Health Information Management Association, 2014[\/footnote][footnote]HSO, 2023[\/footnote]","rendered":"<p>NPs working in LTC may be expected to document. Poor documentation practices in LTC:<\/p>\n<ul>\n<li>May contribute a delayed response to a change in health status<\/li>\n<li>May negatively affect a resident&#8217;s safety, health, and wellbeing<\/li>\n<li>May negatively affect patient health outcomes<\/li>\n<li>Contribute to critical incidents<\/li>\n<\/ul>\n<p>The Medical Record may include:<\/p>\n<ul>\n<li>Advance Care Plan<\/li>\n<li>Medical history<\/li>\n<li>Medications<\/li>\n<li>NP\/MD progress notes<\/li>\n<li>Progress notes by team<\/li>\n<li>Documented physical exams<\/li>\n<li>Care plans<\/li>\n<li>Consult notes from specialist<\/li>\n<li>Diagnostics \u2013 labs and imaging<\/li>\n<li>Admission and discharge summaries<\/li>\n<li>Resident Assessment Instrument (RAI) Assessments<\/li>\n<li>Comprehensive assessments<\/li>\n<\/ul>\n<p>Effective documentation facilitates:<\/p>\n<ul>\n<li>Health care providers having the right patient health information at the right time to guide decision making<\/li>\n<li>High quality comprehensive care that is resident centered, holistic, and inclusive<\/li>\n<li>Continuity of care and safe transfers in care amongst rotating staff<\/li>\n<li>Effective individualized care plans<\/li>\n<li>Interdisciplinary team mobilization to effectively meet a resident\u2019s needs<\/li>\n<li>Accurate data to facilitate quality RAI assessments<\/li>\n<li>Effective infection control practices<\/li>\n<\/ul>\n<p>LTC National Standards: Individualized Care Plan<\/p>\n<ul>\n<li>Ongoing documentation of needs<\/li>\n<li>An accurate problem list that captures active issues and their treatment plans<\/li>\n<li>Residents\u2019 goals of care, preferred level of medical information, needs, and preferences<\/li>\n<li>Team members involved in care<\/li>\n<li>Safety plans \u2013 risk for elopement, substance use, aggression<\/li>\n<\/ul>\n<p><a class=\"footnote\" title=\"American Health Information Management Association, 2014\" id=\"return-footnote-670-1\" href=\"#footnote-670-1\" aria-label=\"Footnote 1\"><sup class=\"footnote\">[1]<\/sup><\/a><a class=\"footnote\" title=\"HSO, 2023\" id=\"return-footnote-670-2\" href=\"#footnote-670-2\" aria-label=\"Footnote 2\"><sup class=\"footnote\">[2]<\/sup><\/a><\/p>\n<hr class=\"before-footnotes clear\" \/><div class=\"footnotes\"><ol><li id=\"footnote-670-1\">American Health Information Management Association, 2014 <a href=\"#return-footnote-670-1\" class=\"return-footnote\" aria-label=\"Return to footnote 1\">&crarr;<\/a><\/li><li id=\"footnote-670-2\">HSO, 2023 <a href=\"#return-footnote-670-2\" class=\"return-footnote\" aria-label=\"Return to footnote 2\">&crarr;<\/a><\/li><\/ol><\/div>","protected":false},"author":517,"menu_order":13,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-670","chapter","type-chapter","status-publish","hentry"],"part":63,"_links":{"self":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapters\/670","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/wp\/v2\/users\/517"}],"version-history":[{"count":1,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapters\/670\/revisions"}],"predecessor-version":[{"id":671,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapters\/670\/revisions\/671"}],"part":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/parts\/63"}],"metadata":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapters\/670\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/wp\/v2\/media?parent=670"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapter-type?post=670"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/wp\/v2\/contributor?post=670"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/wp\/v2\/license?post=670"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}