Transcript Section_4_Maintain_Records

Initiation and Modification of
Therapeutic Procedures
Maintain Records and Communicate Information
Without proper record keeping
 The therapy you provide may not be reimbursable
 The hospital may get cited for improper record keeping
 Your patient may be harmed
CRT EXAM
 Requires knowledge of may facts, standards, and
requirements for maintaining records and
communication with other health care workers, patients,
and family members
 Requires application of the rules and standards for record
keeping and communication while paying close
attention to detail
 Areas of emphasis include charting rules and standards,
communication and coordination of patient care, and
patient education, including smoking cessation
education
Accept and Verify Patient Care
Orders
ACCEPTING ORDERS
If you accept orders:
They must come from an authorized health care provider with
prescribing privileges.
You cannot accept orders transmitted to you via unauthorized third
parties (i.e. RN’s)
If transmitted via a third party you must verify the order in the
patient’s chart
You should not accept blanket orders (e.g. “continue previous
medications”
Accept and Verify Patient Care
Orders
VERIFYING ORDERS
 It is your duty to assure that all respiratory care orders are
accurate and complete
 If an order is incomplete or fails outside established
institutional standards you should contact the prescriber
for clarification before implementing the request
Recording Therapy and Results
BASIC RULEs FOR MEDICAL RECORD KEEPING
Good record keeping begins with careful attention to
detail, requires proper use of terminology and
abbreviations, and involves knowledge of how to make
needed corrections or deletions to a patient’s record
NBRC expects that you know all the standard respiratory
care abbreviations and symbols used on the exam.
 Guidelines for Authors, Respiratory Care Journal
Recording Therapy and Results
SPECIFYING THERAPY ADMINISTERED
“if it wasn’t charted, it wasn’t done”
Whenever you provide therapy to, or obtain diagnostic
information from a patient, you must record the relevant
details and, as necessary, communicate this key information
to other members of the patient’s health care team
Recording Therapy and Results
NOTING AND INTERPRETING THE PATIENT’S RESPONSE TO
THERAPY
Effects of therapy, adverse reactions, and patient’s
subjective and objective response
 What you need to chart depends on
 The expected outcomes of the prescribed procedure
 What parameters you should be monitoring prior to,
during, and after the procedure
 What measures are available to evaluate the expected
outcomes
 The NBRC expects that you will properly chart any adverse
reactions the patient may exhibit during or after the
procedure
Recording Therapy and Results
NOTING AND INTERPRETING THE PATIENT’S RESPONSE TO
THERAPY (cont.)
Essentially all this key information for most respiratory care
procedures is provided in the AARC clinical practice
guidelines
Each guideline provides pertinent information on
 Expected outcomes (Indications and Assessment of
Outcomes)
 What to monitor (Monitoring)
 What adverse reactions to look for (Hazards/Complications)
Recording Therapy and Results
SOAP NOTES
 When using this method it is best to phrase your plan
element of your chart entry as a recommendation
 You should incorporate SOAP actions into your daily
clinical care, and whenever responding to NBRC Exam
questions
Recording Therapy and Results
VERIFYING COMPUTATIONS AND NOTING ERRONEOUS DATA
 All computations must be precise and accurate
 Use the proper tools and techniques for precision
 Check your results to ensure accuracy
 Never report data about which you are unsure
 You must be able to
 Recognize and/or deal with conflicting data
 Recognize plainly incorrect data
 Identify and derive essential but missing information
Recording Therapy and Results
VERIFYING COMPUTATIONS AND NOTING ERRONEOUS DATA
(cont)
 You must know how to apply common formulas and
equations that appear on the Exam.
 Whenever a question involves any numeric data you
should:
 Inspect the data for obvious errors
 Inspect the data for discrepancies
 Review the numbers to see what, if anything, is missing
Communicating Information
The NBRC assesses your communication skills in:
Reporting the patient’s clinical status
Coordinating the patient’s care
Planning for patient discharge
Communicating Information
You should communicate directly to the physician as soon
as possible when
Your written plan includes any recommendations for a
change in therapy
Any unexpected response to therapy or adverse effects
are noted
The more serious the problem, the sooner the key personnel
(attending physician and nurse) must be informed
If it is clear the patient’s vital signs are deteriorating, you
should call for the rapid response team
Communicating Information
You should also participate in coordinating the patient’s
care
Work with the patient’s nurse and/or physician to
schedule the therapy you provide at times:
 Least likely to conflict with other treatments, tests, or meals
 Most likely to coincide with either the administration or
holding of medications
Explaining Planned Therapy and
Goals to Patients
To provide effective respiratory care you must properly explain
to your patients both what needs to be done and why.
Exam focuses on your ability to “translate” therapeutic goals
and/or procedural terminology into terms a layperson can
understand
Know the methods and expected outcome of the
applicable procedures
Be able to use appropriate language to express this
information the patients and their families
The key is to always avoid using medical terminology.
Communicating Results of Therapy
and Alter Therapy According to
Protocol
When implementing a protocol, make sure you are familiar
with
 The limits (boundaries) within which you are permitted to
make independent adjustments
 What conditions require physician notification
Educating Patient and Family
Exam focuses on providing education on smoking cessation
and disease management.
Assessing the patient’s learning needs (i.e. desire to quit
smoking)
Educational strategy based upon the five R’s
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Relevance
Risks
Rewards
Roadblocks
Repetition
Common Errors to Avoid on the Exam
 Never accept an incomplete order, a blanket order, or an
order transmitted to you via an unauthorized third party
 Never use medical or technical terms with patients or their
families when explaining procedures or providing patient
education
 Never erase entries in a medical record; instead always line it
out and write “error” above the line-out
 Avoid using any banned abbreviations and request
clarification if an order contains them
 Never allow unauthorized individuals access to any patient’s
health care information.
Exam Sure Bets
 Always read back and confirm a telephone order,
and note the phone order in the chart
 Always contact the physician and request an
explanation before proceeding with any order that
falls outside established standards, such as normal
drug dosage
 Always document each patient encounter with an
assessment of the intervention and the patient’s
response to it
More Exam Sure Bets
 Always chart a patient’s refusal of therapy and
reason, if provided
 Always communicate any recommendations
for a change in therapy directly to the
prescribing physician as soon as possible
 Always verify that the appropriate information
has been received by those to whom you
“handed off” a patient
More Exam Sure Bets
 Always notify the physician if any significant change
occurs when managing a patient via a respiratory
care protocol
 Always respect the patients’ privacy rights and their
right of access to their own health information
 Always recommend both counseling and
pharmacologic support for patients who desire to
quit smoking
Reference:
Certified Respiratory Therapist Exam Review Guide, Craig Scanlon,
Albert Heuer, and Louis Sinopoli
Jones and Bartlett Publishers