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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. |
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Discuss the purpose of
health or medical records |
Communication
Financial billing Research Auditing-monitoring |
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Describe the difference
between subjective and objective data |
Subjective data: what the
patient says, “exactly”; the patient reports Objective data: Nurses’ assessment via senses, factual, quantitative/qualitative. The result of direct observation and measurement. |
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Differentiate between:
Narrative |
Traditional method for recording
nursing care, use of story like format to document information specific to client condition and nursing care |
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SOAP
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Subjective - Objective -
Assessment - Plan Typically medical point of view |
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Focus charting
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A charting format broken down
into sections. DAR notes: Data - Action - Response Data - includes problem Action - interventions by RN Response - pt response to action |
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Charting by exception
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Only documenting data that
is to be the exception of normal/expected. |
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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 easily. Probelm oriented - Identify each of the problems of pt and organized by probelm. PNA - MD, RN, RT, Labs, etc sometimes hard to find |
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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, confidentiality |
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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. |
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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 |
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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 |
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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 |
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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 entries |
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Discuss the rationale for
JACHO guidelines regarding documentation |
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 assessment |