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15 Cards in this Set

  • Front
  • Back
Define documentation
Anything written or printed
that is relied on as a record
or proof for authorized
persons. It provides evidence
and is a form of communication
between members of the health
care team.
Discuss the purpose of
health or medical records
Financial billing
Describe the difference
between subjective
and objective data
Subjective data: what the
patient says, “exactly”; the
patient reports
Objective data: Nurses’
assessment via senses,
quantitative/qualitative. The
result of direct observation
and measurement.
Differentiate between:
Traditional method for recording
nursing care, use of story like
format to document information
specific to client condition and
nursing care
Subjective - Objective -
Assessment - Plan
Typically medical point of
Focus charting
A charting format broken down
into sections. DAR notes:
Data - Action - Response
Data - includes problem
Action - interventions by RN
Response - pt response to
Charting by exception
Only documenting data that
is to be the exception of
Differentiate between
source records and
probelm-oriented records
Source - different aspects of
care. Chart broken down into
RN, MD, Labs, Consults, ect
sections. Can locate things
Probelm oriented - Identify
each of the problems of pt
and organized by probelm.
PNA - MD, RN, RT, Labs, etc
sometimes hard to find
Discuss computer
documentation applications.
Allows access for authorized
health care providers.
Easy access to patient’s file,
fast retrieval.
Improved uniformity, accuracy
Ability to retrieve info
selectively and choose several
formats to view it in.
standardized forms, timeliness
accuracy, less flexible,
Discuss specific pt activities
requiring consent forms
and nursing responsibilities
Consent forms need to be
signed for all routine
treatments, hazardous
procedures, such as surgery,
some treatments like
chemotherapy, and research.
A general consent is signed
when patients are admitted to
the hospital or other health
care facility.
Special treatment consent
forms are signed before
specialized procedures or
treatments are performed.
Discuss the incident report
in the hospital including
who is required to complete
it and the purpose
of the document
Any event not consistent with
routine operation, witness
writes report, tacts trends
identifies deficits,
rationalization for
education, change
Compare the incident report
to the ARC QI form
A QI form is given to a
student because critical
elements and behaviors
important to nursing care and
patient safety that failure to
perform then correctly is
considered unsafe nursing care
Identify ways to maintain
confidentiality of
records and reports
Legally and ethically
bound. only staff w/ direct
involvement, pts have right
to access own records, SNARC,
no public discussion, quiet
voice, close pt door/curtain
close/return charts, do not
discuss pt info with
uninvolved staff
Identify legal guidelines
for recording
Write legibly
use agency approved
charting type
use agency approved abbrev.
chart after action/intervention
sign/initial and date all
Discuss the rationale for
JACHO guidelines regarding
effective documentation
ensures continuity of care,
saves time, and minimizes the
risk of errors. Accurate
documentation is one of the
best defenses for legal claims
associated with nursing care.
To limit nursing liability,
nursing documentation must
clearly indicate that
individualized, goal-directed
nursing care was provided to a
client based on the nursing