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15 Cards in this Set

  • Front
  • Back
What role does documentation play in nursing?
Ensures continuity of care, saves time, minimizes the risk of errors.
Communication of the healthcare team both written and verbal. Financial re-imbursement
What is multidisciplinary communication?
nurse to nurse
nurse to doctor
lab, x-ray to nurse and doctor
doctor to doctor
If you make an error while recording who do you correct the error?
Draw a single line through the error and initial above it. Then record the note correctly.
How do you add additional information to a chart?
If additional information needs to be added to an existing entry, write the date and time if the the new entry on the next available line and include "addendum to note of (date and time of proir note).
What do you do if you forgot to chart during a shift?
write the current date and time in the next available space, and write "late entry for (date and time/shift missed)"
What do you do to prevent another person from adding incorrect information in your nurses notes?
Do not leave blank spaces in nurses' notes. Chart consecutavely, line by line; if space is left, draw line horizontilly through it, and sign your name at the end
What do you do to prevent another person from adding incorrect information in your nurses notes?
chart that "Dr. Smith was called to clarify order for analgesic."
What can we as nurses do to prevent information from being accidentally deleted?
Avoid using generalized phrases such as "status unchanged" or " had a good day". Use complete, concise descriptions of care
How can you maintain security and confidentiallity when documenting on a computer?
Keep your password to yourself. Once logged into the computer, do not leave the computer screen unattended.
What are some examples of factual things that you would record in the pt's chart?
The report must contain descriptive, objective information about what the nurse sees, hears, feels, and smells. When recording something the client stated ALWAYS use the exact words of the pt and be sure that you record those statements in quotation marks
How can you ensure accurate reporting?
Always sign your entries with your full name and title. Records need to reflect accountability during time frame of entry, which is best accomplished when nurses only chart their own observations and actions. If information was inadvertently omitted from the record, it is acceptable for the nurses to ask colleagues to chart information after they leave work.
How can you ensure that your reporting is complete?
the information within a recorded entry or a report needs to be complete, containing appropriate and essential information. Your recording needs to be very thorough.
Why is it so improtant to keep the client's ongoing care current?
To increase accuracy and decrease unnecessary duplication, many health care agencies use records kept near the client's bedside, which facilitates immediate documentation. Activities that need to be documented at the time of the occurance are:
vital signs
admin. of medication
prep for diagnostic tests
change in status and who was notified
admission, transfer, discharge, or death
treatment for a sudden change in pt's status
What is computerized documentation?
A complete computer-based patient care record is a comprehensive system that uses may components of data collection./
What are the objectives of computer-based patient care recording?
1) Improved uniformity, accuracy, and retrievablility of data about client care
2) Aonfidentiality of health care information ensured in the system
3) Access for authorized health care providers form any department
4) Ability to retrieve information selectively and choose various formats for examining it
5) Assistance with clinical application, including analysis tools, risk assessment, and clinical reminders