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16 Cards in this Set
- Front
- Back
List 6 reasons for the importance of documentation
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1. Legal protection
2. Professional responsibility 3. Quality assurance 4. Education and/or research 5. Regulatory standards 6. Basis for care planning, coordination and continuity of care |
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List 4 desired outcomes of documenting
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1. Reflects the nursing process
2. Charting follows the plan of care (if not, reason are documented) 3. Legally sound documentation 4. Effective communication and maintenance of confidentiality |
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List 4 factors that affect documentation
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1. fax machines (not a good means
of communication and jeopardizes confidentiality) 2. Computerized charting (not yet a standardized language) 3. Accountability (chart your actions only) 4. Time of documentation (try to document immediately following your actions or as soon as you can) |
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List the 5 types of documentation systems
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1. Narrative
2. Problem-Oriented Medical Records (POMR) 3. Source Records 4. Charting by exception (CBE) 5. Case Management or Critical Pathways |
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Identify the type of documentation based on the following points:
1. Client’s chart has separate sections for each discipline 2. Advantage: caregivers can locate proper section of record 3. Disadvantage: same problem distributed throughout record |
SOURCE RECORDS
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Identify the type of documentation based on the following points:
1. Specific to client conditions and nursing care and primarily used in psychiatric nursing 2. Advantages: flexible, strongly conveys nursing interventions and client responses 3. Disadvantages: redundancy, unstructured, time consuming |
NARRATIVE
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Identify the type of documentation based on the following points:
1. Only document significant or abnormal findings, all standards of care are met unless otherwise documented 2. Advantages: reduces repetition and ensures concise documentation 3. Disadvantages: legalities, client and family perspectives |
CBE - Charting by Exception
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Identify the type of documentation based on the following points:
1. Emphasizes pt problems, consists of a data base, problem list, plan of care and progress notes 2. Advantages: focus on the pt problems, information and interventions are clear, and it reflects the nursing process 3. Disadvantages: time consuming, negative connotation (focus on the pt problems) |
POMR - Problem-Oriented Medical
Records |
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Identify the type of documentation based on the following points:
1. Identifies expected outcomes for each day/type of care 2. Includes 3 types of charting methods |
Critical Pathways
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Critical pathway documentation includes 3 types of charting methods. List and define. (hint: D-A-R - define the letters)
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1. S-O-A-P (-I-E-R)
S - subjective O - objective A - assessment P - plan I - intervention E - evaluation R - revision 2. P-I-E P - problem I - intervention E - evaluation 3. D-A-R (focus charting) D - data A - assessment R - pt response |
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List 5 guidelines for documentation
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1. Use only black or blue ink
2. 24 hr clock (e.g. 2200 hrs is 10 p.m. 3. Chronological order 4. Must be legible 5. Use approved terminology and abbreviations |
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List the 7 things you should never chart
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1. Avoid using labels to describe
your patient's behavior. 2. Don't refer to staffing problems. 3. Refrain from mentioning that an incident report has been filed. 4. Don't try to explain a mistake or use words like "accidentally" 5. Avoid airing "dirty laundry." 6. Never chart that you've "informed" a colleague of an event if you really only mentioned it. 7. Never refer to another patient by name. |
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Give 4 rules for charting defensively
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1. Avoid labelling
2. Be specific 3. Eliminate bias 4. Keep neutral language |
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Which of the following should an incident report not include?
A. Patient response B. Name of Dr. notified C. Your name D. Assessment of the patient |
C. Your name
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There are 4 means of communicating with colleagues upon work shift changes. What are they?
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1. Face to face
2. Audio tape 3. Walking rounds 4. Written out |
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When calling a Dr. or changing a shift what protocol should be used? Explain
A. D-A-R B. S-B-A-R C. S-D-E-O D. P-O-M-R |
B. S-B-A-R
(situation, background, assessment, communication) |