Study your flashcards anywhere!

Download the official Cram app for free >

  • Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key


Play button


Play button




Click to flip

66 Cards in this Set

  • Front
  • Back
An Audit is a review of client records for quality assurance purposes. Ex. JACHO audits health care agencies.
All information about a client, includes nursing health history and physical assessment, physician's history, physical examination, lab and diagnostic test results.
A record of the progess of specific or specialized data such as vital signs, fluid balance, or routine medications; often charted in graph form.
Incident Report
It is an agnecy record of an accident or unusual occurance.
The trade name for a method that makes use of a series of cards to concisely organize and record client data and instructions for daily nursing care-especially care that changes frequently and must be kept up to date.
Medical Record
A written transcript of information obtained from a patient, guardian, or medical professional concerning a patients health history, diagnostic tests, diagnosis, treatment, and prognosis.
Nursing Care Conference
It is a metting of a group of nurses to discuss possible solutions to certain problems of a client, such as inability to cope with an event or lack of progress toward goal attainment. THis conference allows each nurse an opportunity to offer an opinion about possible solutions to the problem.
Nursing Care Records
Used to record daily nursing care.
Problem-oriented medical record
Established by Lawrence Weed in the 1960's. The data is arranged according to the problems the client has rather than the source of informations.
The process of making an entry on a client record. It is also known as charting or documenting.
Source oriented medical record
The traditional client record. Each person or department makes notations in a seperate section or sections of the clients chart.
2. Identify the reasons why a clients record is kept.
Communication, PLanning Client Care, Auditing Health Agencies, Research, Education, Reimbursement, Legal Documentation & Health Care Analysis
The record serves as the vehicle by which different health professionals who interact with a client communicate with each other. This prevents fragmentation, repetition and delays in client care.
2.Planning Client Care
Each health professional uses data from the client's record to plan care for that client.
2.Auditing Health Agencies
Client records are kept for quality assurance purposes.
The information contained in a record can be a valuable source of data for research. The treatment plans for a number of clients with the same health problems can yield information helpful in treating other clients.
Students in health disciplines often use client records as educational tools. A record can frequently provide a comprehensive view of the client, the illness, effective treatment strategies and factors that effect the outcome of the illness.
Documentation also helps a facility receive reimbursement from the federal government.
2.Legal Documentation
The clients' record is a legal document and is usually admissible in court as evidence. In some jurisdictions, however, the record is considered inadmissible as evidence when the client objects, because the information the client gives to the physician is confidential.
2.Health Care Analysis
INformation from records may assist health care planners to identify agency needs, such as over utilized hospital services. Records can be used to establish the costs of various services and to identify those services that cost the agency money and those that generate revenue.
3. Source-oriented record
It is a traditional record. Each person or department makes notations in a seperate section or sections of the client's chart. ADVANTAGE: Prodivers from each discipline can easily locate the forms on which to record data and it is easy to trace the information specific to one's discipline.
DISADVANTAGE: Information about a particular client problem is scattered through the chart, so it is difficult to find choronological information on a client's problems and progress.
3.Problem-oriented medical record (POMR)
The data is arranged according to the problems the client has rather than the source of the information members of the health care tream contribute the problem list, plan of care, and progress notes.
ADVANTAGE: It encourages collaboration and the problem list in the front of the chart alerts caregivers to the clients needs and makes it easier to track the status of each problem.
DISADVANTAGES: Caregivers differ in their ability to use the required charting format, it takes constant vigilance to maintain an up-to-date problem list, and it is somewhat inefficient because assessments and interventions that apply to more than one problem must be repeated.
3.Problem-oriented medical record-4 basic components
2)Problem List
3)Plan of Care
4)Progress Notes
4.Compare and contrast the following methods of writing progress notes:
Progress Notes, narrative, SOAP, PIE, and focus.
4. Progress Note
A progress note in the problem-oriented medical record is a chart entry made by all health profrssionals involved in a client's care. They all use the same type of sheet for notes. Progress notes are numbered to correspond to the problems on the problem list and may be lettered for the types of data.
4.Narrative Charting
A traditional part of the source-oriented record. It consists of written notes that include routine care, normal findings and client problems. There is no right or wrong order to the information, although chronological order is frequently used.
SOAP is the acronym for subjective date, objective data, assessment and planning.
Subjective data consits of information obtained from what the client says. It describes the clients perceptions of and experience with the problem. When possible the nurse quotes the client's words; otherwise they are summarized. Subjective date are included only when it is important and relevant to the problem.
Objective data consist of information that is measured or observed by use of the senses, ex: vital signs, lab and x-ray results.
Assessment is the interpretation or conclusion drawn about the subjective and objective data. During the initial assessment, the problem list is created fromt he data base, so the "A" entry should be a statement of the problem. In all subsequent SOAP notes for that problem, the "A" should describe the clients condition and level of progress rather than merely restating the diagnosis or problem.
The plan is the plan of care designed to resolve the stated problem, the initial plan is written by the person who enters the problem into the record.
(Upgrade of SOAP, over the years)
I:Intervention refers to the specific interventions that have actually been performed by the caregiver.
E:Evaluation includes client responses to nursing interventions and medical treatments.This is primarily reassessment data.
R:Revision reflects care plan, modifications sugguested by the evaluation. Changes may be made in desired outcomes, interventions or target dates.
PIE is the acronym for PROBLEM,INTERVENTIONS, and EVALUATION of nursing care. This system consists of a client care assessment flow sheet and progress notes. The PIE system eliminates the traditional care plan and incorporates an ongoing care plan into the progress notes.
4.Focus Charting
Is intended to make the client and clients concerns and strengths the focus of care. 3 columns for recording are usually used, date & time, focus and progress notes. The progress notes are organized into DAR, D-Data,A-Action,& R-Response. The nurse reports both objective and subjective data in this section.
5.Discuss charting by exception (CBE).
CBE- is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded. CBE incorporates 3 key elements.
1.FLOW SHEET- Examples of flow sheets include a graphic record, fluid balance record, daily care record, client teachings record, client discharge record, and skin assessment record.
2.STANDARDS OF NURSING CARE: Documentation by reference to the agency's printed standards of nursing practice eliminates much of the repetitive charting of routine care.
3.BEDSIDE ACCESS TO CHART FORMS:In the CBE system all flow sheets are kept at the client's beside to allow immediate recording and to eliminate the need to transcribe data from the nurse's worksheet to the permanent record. The advantage to this system is the elimination of lengthy, repetitive notes and it makes client changes in condition more obvious.
5.Discuss Case Management
This model emphasizes quality, cost-effective care delivered within an established length of stay. This model uses a multidisciplinary approach to planning and documenting client care, using critical pathways.These forms identify the outcomes that certain groups of clients are expected to achieve on each day of care, along with interventions necessary for each day.
6.List the pros and cons of computer documentation.

*Computer records can facilitate a focus on client outcomes.
*Bedside terminal can synthesize info from monitoring equiptment.
*Allows nurses to use their time more efficiently.
*The system links various sources of client information.
*Client information, requests, and results are sent and received quickly.
*Links to monitors improve accuracy of documentation.
*Bedside terminals eliminate the need to take notes on a worksheet before recording
*Bedside terminals permit the nurse to check an order immediately before administering a treatment or medication
*Information is leigible.
*The system incorporates and reinforces standards of care.
*Standard terminology improves communication.
*Client's privacy maybe infringed on if security measures are not used.
*Breakdowns make information temporarily unavailable.
*System is expensive.
*Extended training periods may be required when a new or updated system is installed.
7.Discuss the use of a Kardex system. Include the types of information found in a Kardex.
The Kardex is widely used, concise method of organizing and recording data about a client, makeing information quickly assessable to all health professionals. The system consists of a series of cards kept in a portable index file or on computer generated forms.The information on Kardexes maybe organized into sections.
*Pertinent information about the client, such as name, room number, age, religion, martial status, admission date, physician's name, diagnosis, type of surgery and next to kin.
*List of medications, with the date of order and the times of administration for each.
*List intravenous fluids, with dates of infustions
*List of daily treatments and procedures, such as irrigations, dressing changes, postural drainage, or measurement of vital signs.
*List of diagnostic procedures ordered, such as x-rays or alboratiry tests
*Specific data on how the clients physical needs are to be met, such as type of diet assistance needed with feeding, elimination devices, activity, hygienic needs and safety precautions.Ex:One-Preson assist.
*A problem list, stated goals and a list of nursing approaches to meet the goals and relieve the problems.
8.Discuss the use of the following types of flow sheets: graphic record, fluid balance record, MAR and skin assessment record.
A flow sheet enable the nurse to record nursing data quickly and concisely and provides an easy-to-read record of the client's condition overtime.
8.Graphic Record
This record typically indicates body temperature, pulse, respiratory rate, blood pressure, weight and in some agencies, other significant clinical data such as admission or post operative day, dowel movements, appitite, and activity.
8.Fluid Balance Record
All routes of fulid intake and all routes of fluid loss or output are measured and recorded on this form.
8.Medication Administration Record (MARS)
Medication flow sheets usually include designated areas for the date of the medication order, the expiration date, the medication name and dose, the frequency of administration and route and the nburses signature. Some records also include a place to document the client's allergies.
8.Skin Assessment Record
A skin or wound assessment is often recorded on a flow chart. These records may include catergories related to stage of skin injury, drainage, odor, culture information, and treatments.
9.Discuss the purpose of nursing discharge, refferal summary.
A discharge note and refferal summary are completed whent he client is being discharged and transferred to another insitution or to a home setting where a visit by a community health nurse is required. Many institutions provide forms for these summaries. Some records combine the discharge plan, including instructions for care, and final progress note. If the discharge plan is given directly to the client and family, it is imperative that instructions be written in terms that can be readily understood. If a client is transfered within the facility or from a long-term facility to a hospital, a report needs to accompany the client to ensure continuity or care in the new area. It should include all components of the discharge instructions, but also describe the condition of the client before the transfer. Any teaching or client instruction that has been done should also be described and recorded.
10.Discuss general guidelines for recording the clients chart.
(Date & Time)
Document the date and time of each recording. This is essential not only for legal reasons but also for the client's safety. record the time in the convential manner or according to the 24-hours clock (military clock), which avoids confusion about whether a time was AM or PM.
10. Timing
Follow the agencies policy about the frequency of documenting and adjust the frequency as a client's condition indicates. Documenting should be done as soon as possible after an assessment or intervention. No recording should be done prior to providing nursing care.
10. Legibility
All entries must be legible and easy to read to prevent interpretation errors. Hand printing opr easily understood handwriting is usually permissible. Follow agency's policies about handwritten recording.
All entries on the client's record are made in dark ink so that the record is permanent and changes can be identified. Dark ink reproduces well on microfilm and in duplication processes. Follow the agency's policies about the type of pen and ink used for recording.
10.Accepted Terminology
Use only commonly accepted abbrevations are standard and used universally; others are used only in certain geographic areas. Many health care facilities are required to supply an approved list of abbrevation, write out the full term until certain about the abbreviation. Abbreviations can lead to misunderstandings. The nurse should know and use only the approved list of abbreviations at the facility to avoid putting a client at potential risk.
10.Correct Spelling
Correct spelling is essential for accuracy in recording. Two decidedly different medications may have similar spellings.
Each recording on the nursing notes is signed by the nurse making it official. The signature includes the name and title. Some agencies have a signature sheet and after signing this signature sheet, the nurse can use their initials. With computerized charting, each nurse has his/her own code, which allows the documentation to be identified. Nurse need to follow agency policy about how to sign their names.
The client's name and identifying information should be stamped or written on each page of the clinical record. Before making any entry, check that it is the correct chart. Do not identify charts by room number only; check the client's name. Special care is needed when caring for clients with the same last name. Notations on records must be accurate and correct. Accurate notations consist of facts or observations rather than opinions or interpretations. Write on every line but never between lines. If a blank appears in a notation, draw a line sthrough the blank space so that no additional information can be recorded at any other time or by any other person and sign the notation.
Document events int he order in which they occur. Update or delete problems as needed.
Record only information that pertains to the client's health problems and care. Any other perconal information that the client conveys is inappropriate for the record. Record irrelevant information maybe considered an invasion of the client's disclosure.
Not all data that a nurse obtains about a client can be recorded. The information that is recorded needs to be complete and helpful to the client and health care professionals. Nurse's notes need to reflect the nursing process. Record all assessments, dependent and independent nursing interventions and tests and progress toward goals and communication with other members of the health team. Care that isomitted because of the client's condition or refusal of treatment must also be recorded. Document what was omitted and why it was omitted, and who was notified.
Recordings need to be breif as well as complete to save time in communication. The client's name and the word client are omitted.
10.Legal Prudence
Accurate, complete documentation should give legal protection to the nurse, the client's other caregivers, the health care facility, and the client. Admissible in court as a legal document, the clinical record provides proof of the quality of care given to a client. Documentation is usually viewed by injuries and attorneys as the best evidence of what really happened to the client.

For best legal protection, the nurse should not only adhere to professional standards of nursing care but also follow agency policy and procedures for intervention and documentation in all situations.
11.Identify key elements of a change-of-shift report.
*Follow a particular order
*Provide basic identifying information for each client.
*For new clients, provide the reason for admission or medical diagnosis, surgery, diagnostic tests, and therapies in the past 24 hours.
*Include significant changes in client's condition and present informationin order
*Provide exact information
*Report client's need for special emotional support.
*Include current nurse prescribed and physician prescribed orders.
*Provide a summary on newly admitted clients, including diagnosis, age, general condition, plan of therapy, and significant ionfoprmation about the client's support people.
*Report on clients who have been transferred or discharged for the unit.
*Clearly state priorities of care and care that is due after the shift begins.
*Be concise. Don't elaborate on background data or routine care. Do not report comings and goings of visitors unless there is a problem or concern, or visitors are involved in teaching and care, social support and visits are the norm.
12.Discuss the following ways of reporting client information:
Telephone reports, telephone orders, care plan conference and norsing record.
12.Telephone Reports
Health professionals frequently report about a client by telephone. Nurses inform physicians about a change in a client's condition. The nurse receiving a telephone report should document the date and time, the name of the person giving the information, and the subject of the information received and sign the nortation. If there is any doubt about the information given over the phone, the person receiving the information should repeat it back to the sender to ensure accuracy. When giving a telephone report to the physician, it is important that the nurse be concise and accurate.
-Begin with the name and relationship to the client.
-The nurse should have the client's chart ready to give the physician any further information.
-After reporting, the nurse should document the date, time and content of the care.
12.Telephone Orders
Physicians often order a therapy for a client by telephone. Most agencies have specific policies about telephone orders. Many agencies allow only registered nurses to take telephone orders.
...While the physician gives the order....
-Write it down & repeat it back to the physician to ensure accuracy.
-Question the physician about any order that is ambiguous, unusual or contraindicated by the client's condition.
-Then transscribe the order onto the physicians order sheet, indicating it is a verbal order ot telephone order.
-Physician must countersign the order within a time period described by agency policy.
12.Care Plan Conference
A care plan conference is a meeting of a group of nurses to discuss possible solutions to certain problems of a client, such as inability to copt with an event ot lack of progress toward goal attainment. The care plan conference allows each nurse an opportunity to offer an opinion about possible solutions to the problem. Nurses need to accept and respect each person's contributions listening with an open mind to what others are saying even when there is a disagreement.
12.Nursing Rounds
Nursing rounds are procedures in which two or more nurses visit selected clients at each client's bedside.
12.Nursing Rounds are done to....
*Obtain information that will help plan nursing care.
*Provide clients the opportunity to discuss their care.
*Evaluate the nursing care that the client has received.

During rounds the nurse assigned tot he client provides a brief summary of the client's nursing needs and the interventions being implemented. Nursing rounds offer advantages to both clients and nurses. Clients can participate in the discussions, and nurses can see the client and the equiptment being used. To facilitate client participation in nursing reounds, nurses need to use terms that the client can understand. Medical terminology excludes the client from discussion.
13.Discuss the use of root words, prefixes and suffixes as they apply to medical terminology...