Kozier Ch 15 (Documentation) - Fundamentals Of Nursing + (Elisa)

Front 1

What is the Purpose of Client Records ? (8 things)

Back 1

-Communication
-Planning client care
-Auditing health agencies
-Research
-Education
-Reimbursement
-Legal documentation
-Health care analysis
(Slide 55.)

Front 2

Why is Maintaining Confidentiality of Records important?(3 things)

Back 2

-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. )

Front 3

What is Source-Oriented Records ?(4things)

Back 3

-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. )

Front 4

What is (POMR)?

Back 4

Problem-Oriented Medical Records
(Slide 58. )

Front 5

What makes Problem-Oriented Medical Records (POMR) easier?

Back 5

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. )

Front 6

What are the Four basic components to POMR?

Back 6

-Database
-Problem list
-Plan of care
-Progress notes
---Uses SOAP, SOAPIE, SOAPIER documentation
(Slide 58. )

Front 7

What is SOAP?

Back 7

-an acronym for
subjective,
objective,
assessment, and
plan

Front 8

Describe PIE Documentation

Back 8

-Groups information into three categories: Problem, Interventions, Evaluation
-Client assessment flow sheet and progress notes
(slide59.)

Front 9

What is Focus Charting ?(4things)

Back 9

-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. )

Front 10

What is (DAR) format?

Back 10

-Data -assessment phase
-Action - planning and implementing phase
-Response - evaluation phase
(slide 60. )

Front 11

What is (CBE)?

Back 11

Charting by Exception
(slide 61. )

Front 12

Describe Charting by Exception (CBE)(4 things)

Back 12

-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. )

Front 13

(Define Case Management Model

Back 13

-Quality, cost-effective care delivered within established length of stay
(slide 62.)

Front 14

What 3 things does Case Management Model use?

Back 14

-Uses multidisciplinary approach
-Uses critical pathways
-Uses CBE
(slide 62.)

Front 15

Documentation of variances of Case Management Model includes? (2 things)

Back 15

-Actions taken to correct the situation
-Justification of actions taken
(slide 62.)

Front 16

Why was Computerized Documentation Developed?

Back 16

- to manage volume of information
(slide 63. )

Front 17

How is Computerized Documentation used?

Back 17

-Use of computers to store client’s database, new data; to create and revise care plans; to document client’s progress
(slide 63. )

Front 18

What are the benefit to Computerized Documentation?(3 things)

Back 18

- Information easily retrieved
-Speech-recognition technology
-Possible to transmit information from one care setting to another
(slide 63. )

Front 19

What is done to insure Security for Computerized Records ?(7things)

Back 19

-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.)

Front 20

Joint Commission requires clinical record to include…?(5 things)

Back 20

-Evidence of client assessment
-Nursing diagnosis
-Nursing interventions
-Client outcomes
-Current nursing care plans
(slide 65).

Front 21

How are Traditional care plans done?

Back 21

-Written for each client
(slide 65).

Front 22

What is Standardized care plans Based on?

Back 22

- institutions standards of practice
(slide 65).

Front 23

Define Kardexes

Back 23

-Concise method of organizing and recording data
(slide66.)

Front 24

Why are Kardexes useful?

Back 24

-Information quickly accessible
(slide66.)

Front 25

What7 things are included on Kardexes?

Back 25

-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.)

Front 26

What are Flow Sheets? Give 3 examples.

Back 26

-Graphic record
--Intake and output
--Medication administration record
--Skin assessment record
(slide 67.)

Front 27

Why are Progress Notes important?(2 things)

Back 27

-Provide information about progress client is making toward achieving desired outcomes
-Include information about client problems and nursing interventions
(slide 68.)

Front 28

When is Nursing Discharge done?

Back 28

-Completed when client discharged
--In Terms that can be readily understood
*Client education
(slide 69.)

Front 29

When are Referral Summaries done?

Back 29

Completed when client transferred to another institution
(slide 69.)

Front 30

What do Referral Summaries Include?

Back 30

-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.)

Front 31

Long-Term Care Documentation isBased on…

Back 31

- professional standards, federal and state regulations, policies of health care agency
(slide 70.)

Front 32

Long-Term Care Documentation includes …

Back 32

-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.)

Front 33

How often does Long-Term Care Documentation needs to Review and revise plan of care?

Back 33

- every 3 months or when status changes.
(slide 70.)

Front 34

With Long-Term Care Documentation it is important to Document and report…?

Back 34

- any change.
(slide 70.)

Front 35

What Two records are required for Home Care Documentation ?

Back 35

-Home health certification and plan-of-treatment form
-Medical update and patient information form
(slide 71.)

Front 36

Where is Home Care Documentation Kept?

Back 36

- a copy of the care plan in the client’s home.
(slide 71.)

Front 37

What is important to Report and document in Home Care Documentation?

Back 37

-changes in plan of care.
-Write a discharge summary.
(slide 71.)

Front 38

What is important to remember about Legal and Ethical Standards for Documentation ?

Back 38

-Client’s record are a legal document
-May be used to provide evidence in court
(slide 72.)

Front 39

Legal and Ethical Standards for Documentation include (9 things)?

Back 39

-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.)

Front 40

What is SBAR format?

Back 40

-Situation,
-Background,
-Assessment,
-Recommendation
(slide 75.)

Front 41

Describe Guidelines for Change-of-Shift Report

Back 41

-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.)

Front 42

What 5 things are included in Guidelines for Giving a Telephone Report ?

Back 42

-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.)

Front 43

What 8 components are included in the Guidelines for Telephone and Verbal Orders ?

Back 43

-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. )

Front 44

Who is in charge of Prohibited Abbreviations, Acronyms, and Symbols AKA “Do Not Use” list?

Back 44

-JCAHO National Patient Safety Goals 2004
(slide 79.)

Front 45

Why did JCAHO come up with “Do Not Use” list

Back 45

-To help avoid errors
-Many banned abbreviations refer to medications
-Others are derived from Latin
(slide 79.)

Front 46

Describe the 3 components of a Care Plan Conference?

Back 46

-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.)

Front 47

Describe the Nursing Rounds (4 components )

Back 47

-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.)