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47 Cards in this Set
- Front
- Back
What is the Purpose of Client Records ? (8 things)
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-Communication
-Planning client care -Auditing health agencies -Research -Education -Reimbursement -Legal documentation -Health care analysis (Slide 55.) |
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Why is Maintaining Confidentiality of Records important?(3 things)
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-For purposes of education and research, most agencies allow students and graduates access to client records
-Bound by strict ethical codes and legal responsibility -Protect client’s privacy by not using name or any statements to identify client (Slide 56. ) |
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What is Source-Oriented Records ?(4things)
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-Traditional client record
-Each discipline makes notations in a separate section -Information about a particular problem distributed throughout the record -Narrative charting used (Slide 57. ) |
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What is (POMR)?
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Problem-Oriented Medical Records
(Slide 58. ) |
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What makes Problem-Oriented Medical Records (POMR) easier?
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Data arranged according to client problem
Health team contributes to the problem list, plan of care, and progress notes Encourages collaboration Easier to track status of problems (Slide 58. ) |
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What are the Four basic components to POMR?
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-Database
-Problem list -Plan of care -Progress notes ---Uses SOAP, SOAPIE, SOAPIER documentation (Slide 58. ) |
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What is SOAP?
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-an acronym for
subjective, objective, assessment, and plan |
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Describe PIE Documentation
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-Groups information into three categories: Problem, Interventions, Evaluation
-Client assessment flow sheet and progress notes (slide59.) |
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What is Focus Charting ?(4things)
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-Focus on client concerns and strengths
-Progress notes organized into DAR format -Holistic perspective of client needs -Nursing process framework for progress notes (slide 60. ) |
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What is (DAR) format?
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-Data -assessment phase
-Action - planning and implementing phase -Response - evaluation phase (slide 60. ) |
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What is (CBE)?
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Charting by Exception
(slide 61. ) |
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Describe Charting by Exception (CBE)(4 things)
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-Incorporates flow sheets, standards of nursing care, bedside chart forms
-Agencies develop standards of nursing practice -Documentation according to standards involves a check mark -Exceptions to standards described in narrative form on nurses’ notes (slide 61. ) |
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(Define Case Management Model
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-Quality, cost-effective care delivered within established length of stay
(slide 62.) |
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What 3 things does Case Management Model use?
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-Uses multidisciplinary approach
-Uses critical pathways -Uses CBE (slide 62.) |
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Documentation of variances of Case Management Model includes? (2 things)
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-Actions taken to correct the situation
-Justification of actions taken (slide 62.) |
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Why was Computerized Documentation Developed?
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- to manage volume of information
(slide 63. ) |
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How is Computerized Documentation used?
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-Use of computers to store client’s database, new data; to create and revise care plans; to document client’s progress
(slide 63. ) |
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What are the benefit to Computerized Documentation?(3 things)
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- Information easily retrieved
-Speech-recognition technology -Possible to transmit information from one care setting to another (slide 63. ) |
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What is done to insure Security for Computerized Records ?(7things)
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-Passwords required and should not be shared
-Never leave computer terminal unattended after logging on -Do not leave client information displayed -Shred all unneeded computer-generated worksheets -Know facility’s policy and procedure for correcting an entry error -Follow agency procedures for documenting sensitive material -Installed firewalls (slide 64.) |
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Joint Commission requires clinical record to include…?(5 things)
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-Evidence of client assessment
-Nursing diagnosis -Nursing interventions -Client outcomes -Current nursing care plans (slide 65). |
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How are Traditional care plans done?
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-Written for each client
(slide 65). |
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What is Standardized care plans Based on?
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- institutions standards of practice
(slide 65). |
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Define Kardexes
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-Concise method of organizing and recording data
(slide66.) |
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Why are Kardexes useful?
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-Information quickly accessible
(slide66.) |
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What7 things are included on Kardexes?
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-Pertinent information about the client
-Allergies -List of medications including IV fluids -List of daily treatments and procedures -List of diagnostic procedures -Physical needs to be met -Stated goals (slide66.) |
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What are Flow Sheets? Give 3 examples.
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-Graphic record
--Intake and output --Medication administration record --Skin assessment record (slide 67.) |
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Why are Progress Notes important?(2 things)
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-Provide information about progress client is making toward achieving desired outcomes
-Include information about client problems and nursing interventions (slide 68.) |
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When is Nursing Discharge done?
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-Completed when client discharged
--In Terms that can be readily understood *Client education (slide 69.) |
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When are Referral Summaries done?
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Completed when client transferred to another institution
(slide 69.) |
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What do Referral Summaries Include?
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-description of client’s physical, mental, and emotional status
--Resolved health problems --Treatments to be continued --Current medications -Include restrictions that relate to activity, diet, and bathing *Client education (slide 69.) |
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Long-Term Care Documentation isBased on…
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- professional standards, federal and state regulations, policies of health care agency
(slide 70.) |
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Long-Term Care Documentation includes …
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-Complete assessments, screening forms, and plan of care within the time period.
-Keeping record of visits and phone calls. -Writen nursing summaries and progress notes according to specified time periods. (slide 70.) |
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How often does Long-Term Care Documentation needs to Review and revise plan of care?
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- every 3 months or when status changes.
(slide 70.) |
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With Long-Term Care Documentation it is important to Document and report…?
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- any change.
(slide 70.) |
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What Two records are required for Home Care Documentation ?
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-Home health certification and plan-of-treatment form
-Medical update and patient information form (slide 71.) |
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Where is Home Care Documentation Kept?
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- a copy of the care plan in the client’s home.
(slide 71.) |
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What is important to Report and document in Home Care Documentation?
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-changes in plan of care.
-Write a discharge summary. (slide 71.) |
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What is important to remember about Legal and Ethical Standards for Documentation ?
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-Client’s record are a legal document
-May be used to provide evidence in court (slide 72.) |
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Legal and Ethical Standards for Documentation include (9 things)?
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-Date and time
-Timing -Legibility -Permanence -Accepted terminology and correct spelling -Signature -Accuracy -Sequence -Appropriateness ---Completeness ---Conciseness (no extra details) ---Legal prudence (slide 73.) (slide 74.) |
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What is SBAR format?
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-Situation,
-Background, -Assessment, -Recommendation (slide 75.) |
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Describe Guidelines for Change-of-Shift Report
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-Follow a particular order.
-Provide basic identifying information. -For new clients provide reason for admission or medical diagnosis/es, surgery, diagnostic tests and -therapies in past 24 hours, significant changes in client’s condition. -Provide exact information. -Report client’s need for emotional support. -Include current nurse-prescribed and primary care provider-prescribed orders. -Clearly state priorities of care and care due after shift begins. -Be concise . -Incorporate a verification process. -SBAR format (Situation, Background, Assessment, Recommendation) (slide 75.) |
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What 5 things are included in Guidelines for Giving a Telephone Report ?
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-Be concise and accurate (SBAR often used).
-State name and relationship to client. -State client’s name, medical diagnosis, changes in nursing assessment, vital signs related to baseline, -significant laboratory data, related nursing interventions. -Have chart ready to give any further information needed. -Document date, time, and content of the call. (slide 76.) |
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What 8 components are included in the Guidelines for Telephone and Verbal Orders ?
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-Know who can give and accept orders per state board and agency policy.
-Ask prescriber to speak slowly and clearly and to spell out unfamiliar medication names. -Question any drug, dosage, or change if it seems inappropriate. -Transcribe the order. Write dosages clearly. Use a number before a decimal but not after a decimal (e.g., 0.3 mg but 6 mg, not 6.0 mg). Write out units (15 units, not 15 u). -Record date and time and indicate type of order (TO/RB or VO/RB). -Sign name and credentials. -Follow protocol for having primary care provider sign telephone/verbal orders (i.e., within time described by agency policy). -**Never follow a voicemail order. Call back the prescriber. (slide 77. 78. ) |
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Who is in charge of Prohibited Abbreviations, Acronyms, and Symbols AKA “Do Not Use” list?
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-JCAHO National Patient Safety Goals 2004
(slide 79.) |
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Why did JCAHO come up with “Do Not Use” list
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-To help avoid errors
-Many banned abbreviations refer to medications -Others are derived from Latin (slide 79.) |
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Describe the 3 components of a Care Plan Conference?
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-A meeting of a group of nurses to discuss possible solutions to certain problems of a client
-Allows each nurse the opportunity to offer an opinion about possible solutions -Other health care providers invited to offer expertise (slide 80.) |
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Describe the Nursing Rounds (4 components )
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-Two or more nurses visit selected clients at bedside
-Obtain information that will help plan nursing care and evaluate care given -Provides clients opportunity to discuss their care -Need to use terms client can understand (slide 80.) |