Documentation

Front 1

_____ is anything written or printed that is relied on as record or proof of the nsg process.

Back 1

Documentation

Front 2

The best defense a nurse has if a client/surrogate alleges nursing negligence is _____.

Back 2

-documentation

Front 3

Why do we document?

Back 3

-communication
-quality review
-research
-education
-financial billing
-legal documentation

Front 4

_____ records are the traditional client record. Each person/department makes notes in their own section. Narrative charting is used.

Back 4

Source-oriented

Front 5

The disadvantage of source-oriented records is

Back 5

that information about problems and progress is scattered throughout the chart

Front 6

_____ medical records has data arranged according to the client problem instead of the care provider. The health team coordinates problem list, plan of care and progress via SOAPIER.

Back 6

Problem-oriented

Front 7

Advantages of the problem-oriented medical record are

Back 7

-encourages collaboration
-easier to track status of a problem

Front 8

Disadvantage of the problem-oriented medical record is:

Back 8

-vigilance is required to keep problem list up to date.

Front 9

____ incorporates flow sheets, standards of nsg care, and chart forms. Agencies develop own to decrease excessive charting.

Back 9

Charting by exception (CBE)

Front 10

_____ decreases writing time because you have check boxes.

Back 10

Charting by exception

Front 11

Exceptions to standards is described in ____ on the ____.

Back 11

narrative form
nurse's notes

Front 12

_____ allows management of large volumes of information allowing you to store client data, create and revise care plans and document client progress.

Back 12

Computerized documentation

Front 13

An advantage and disadvantage of computerized documentation is that the

Back 13

information is easily retrievable

Front 14

The _____ of documentation focuses on quality. What can we do to get the patient where he/she needs to be in the least amount of time...

Back 14

Case Management Model

Front 15

The _____ provides quality, cost effective care delivered within an established length of stay. Uses multidisciplinary approach, critical pathways, and CBE.

Back 15

Case management model

Front 16

With the case management model it is important to document any _____. This is an unexpected occurrence.

Back 16

variance

Front 17

When there is a variance you should document...

Back 17

-actions taken to correct situation
-justify actions

Front 18

Critical elements for documenting include:

Back 18

-legibility and permanence
-date and time/timing
-accepted terminology and appropriateness
-correct grammar and spelling
-accuracy/conciseness
-legal prudence
-signature

Front 19

What is necessary for effective communication?

Back 19

- understanding of standards of care
-use of appropriate terms
-use of appropriate writing utensils
-knowledge of policies and procedures

Front 20

Documentation Do's include:

Back 20

-right chart
-write with permanent black ink
-chart all interventions and responses
-follow facility policies and procedures
-charts ASAP after event or care
-read other nurse's notes prior to care
-be objective, factual, specific
-chart all teaching
-record clients "actual words"

Front 21

Documentation Dont's include:

Back 21

-chart symptom without intervention
-write vague descriptions
-alter or falsify medical record
-use unacceptable abbreviations
-document for other people
-use judgmental language
-record staff conflicts or problems
-chart beforehand
-record "patient" or "client"

Front 22

____ is communicating specific information about clients to other healthcare providers. It can be written or oral.

Back 22

Reporting

Front 23

Reporting equates to

Back 23

continuity of care.

Front 24

Communication should include:

Back 24

-up to date information
-interactive communication allowing for ?'s
-method for verifying info.
-minimal interruption
-opportunity for receivers of info to review relevant client data

Front 25

In a ____ nurses and other professionals come together to discuss possible solutions to certain client problems.

Back 25

Care Plan Conference

Front 26

Ways to ensure client confidentiality are:

Back 26

-not using client names on paperwork
-don't leave open charts lying around
-don't discuss client info with persons who are not involved in the care of the client.
-use only last 2 room #'s and initials to identify patient