Fundamentals Of Nursing: Chapter 5

Front 1

charting by exception

Back 1

is quite different from all other types of documentation, only variences from "normal" or exceptions to the rule, are writen as entries, Positive: reduces time spent on paperwork Negative: you may miss or click on something by accident and it didnt really get done, you must have a set boundary from employee what is the "norm"

Front 2

what is the purpose of a written record of the history, treatment, care and response of patient under care?

Back 2

you have to have a baseline of where you started, is the patient responding to treatment, does the pt have allergies, does the pt feel like he is getting better, also for legal reasions as well

Front 3

documentation

Back 3

which is the act of charting or making written notation of all the things that are pertinent to each patient for whom you provide care, permanent med record, evidence of what transpired

Front 4

purposes of documentation

Back 4

1. a written record of the hx, tx, care, response of pt
2. guide for reimbursement for insurance so hospital gets paid
3. use of nursing process
4. provides data for quality assurance studies

Front 5

legal and ethical guidelines for recording in medical records

Back 5

legal record for pt and hospital
2. can prove negligence or malpractice
3. if it wasnt charted, "it wasnt done" and you may have did it and forgot to chart

Front 6

focus charting

Back 6

is focused on the patient and patient concerns, problems and strengths, not as specific as pie charting, a common type of focus charting is DAR , data, action, response

Front 7

kardex

Back 7

contains written data, quick reference regarding each pt's care, it has a page for each pt on the floor, fold in half, used for shift reports, diet, bath, vs, card stock, new orders done by secretaries, some put it in mar and some shred upon discharge

Front 8

narrative charting

Back 8

tells the story of the pt's experiences during the stay, written in chronological order and relates pt health status from admission to discharge, provides more details, disadvantage very time consuming

Front 9

PIE charting

Back 9

is much shorter and documents fewer data than the SOAPIER charting style, it only addresses pt problems the concept of treating this pt holistically is lost

Front 10

P in PIE charting means...

Back 10

problem-this list is built from the collected data to identify the pt's problems

Front 11

I in PIE CHARTING

Back 11

I means interventions, these are the interventions you perform to address the patient's problems

Front 12

E in PIE charting

Back 12

E means evaluation: this is your evaluation of the effectiveness of the interventions you performed

Front 13

SOAPIER charting

Back 13

may be used with either source or problem oriented systems, used mostly in nurses notes and progress notes, pretty lengthy documents, provides organization of entries

Front 14

can be used in both problem oriented and source oriented systems

Back 14

soapier charting, pie charting and narrative charting

Front 15

only can be used in source oriented systems

Back 15

focus charting and charting by exception

Front 16

general guidelines for charting

Back 16

1. use black or blue ink, neatly
2. sign each entry, date & time
3. follow chronological order
4. enter as they happen
5. be succinct, brief, consise, dont have to put "the or a", or pt or client or resident "a note"

Front 17

general guidelines for charting

Back 17

1. use punctuation
2. use only approved abbrev.
3. accurate, dont leave blanks
4. use continued notes
5. correct mistaken entries, put a line thru, write mistaken entry above and initials
6. keep med records intact

Front 18

long term care documentation

Back 18

the fed law "omnibus budget recon act (obra) requires and extensive assessment form called the MDS, mininum data set for resident assessment and care screening completed within 4 (four) days of admission updated every 3 months

Front 19

mds
minimum data set for resident assessment and care screening must be done 4 days after admission, it includes

Back 19

1. demographics, id and background
2. routines, eating patterns, adl's
3. comm, hearing, cognitive, vision
4. mood/behavior, physical
5. bowel/bladder/functions
6. health, disase, meds

Front 20

mar in nursing homes

Back 20

meds are charted on mar, one sheet for entire month

Front 21

home health care,
health care financing agency
hcfa, one admission form is the oasis

Back 21

which means outcome and assessment information set, audited by the state health dept and medicare

Front 22

five documentation mistakes

Back 22

assessment findings
medications administered
pertinent health history
physicians orders
documenting on wrong chart or MAR also carry increased risks

Front 23

focus charting is DAR charting

Back 23

D - data--objective/subj data
A- action-charting my interventions
R-response-patients response to my interventions