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50 Cards in this Set

  • Front
  • Back
What is Documentation?
Documentation is a WRITTEN, legal record of all pertinent interactions with the patient.
Nursing Documentation must be accurate and comprehensive.
Guidelines for Documentation
Policy Statements
Purposes for Recording and Reporting Patient Care
Quality Assurance
-Nurses and other health care providers aim to share accurate, concise, thorough current, organized and confidential information about patients
-Examples: Admitting Nursing History, Physical Assessment
Quality Review
-Audits of reports and records provide another way to evaluate the quality of patients’ care
-Example: JCAHO (Joint Commission Accreditation of Hospital Organization)
-The Diagnosis-related groups (DRGs) have become the basis for establishing reimbursement for client care.
-Example: Reimbursement for Wound Care
Legal/Ethical Obligations
-Patient-related reports and clinical records are legal documents that can be used as evidence in courts of law
-Data derived from patient reports and records are prime sources of information about patient characteristics and responses to interventions
-Nursing students, medical students, and other disciplines use the record as a learning tool
Poor communication Through Documentation
-“By the time he was admitted, his rapid heart rate had stopped, and he was feeling better”
-Patient has chest pain if she lies on her left side for over a year.”
Guidelines for Quality Documentation and Reporting

-timely (current)
-new or changed information
-signs & symptom
-patient behaviors
-nursing interventions
-medication given
-physicians orders carried out
-patient’s teaching and responses
-physician’s verbal/telephone orders
-use precise measurements and time
-use correct spelling and medical terms
-data is clear and easy to understand
-use of an institutions accepted abbreviations

SEE PAGE 838, Table 34-9 “Dangerous Abbreviations Used in Medication Administration”. (Also, Ms. Jefferson had another handout with a longer list. Make sure you look over that list, too.)
-use of appropriate information
-use of essential information
-describing concise nursing care
-describing the client’s response
“Administration of Narcotics”
-requires special documentation:
1) name of narcotic
2) amount administered
3) amount wasted
4) pain scale rating
5) name/signature of person administering
6) name/signature of nurse witnessing waste
-helps avoid errors
-helps avoid forgetting information
-record medication administration and treatments
-record admission, and change in patient status
-systemic / systematic
-chronological flow
-Documentation should be clear and concise
-never skip lines
-proper use of grammar
-use black ink
-do not erase or use correction fluid
-if the nurse makes an error, draw a single line through the error and write the word VOID and sign his/her initials.
Methods of Recording
-Narrative Notes
-Problem-Oriented Medical Record (POMR)
-Source records
-Charting by exception
-Case Management and critical pathways
Narrative Notes
-Traditional Method
-A story format
-Repetitious information
Problem-Oriented Medical Record (POMR)
-provides Database
-problem list
-Nursing care plan
-Progress note: SOAP, PIE, Focus
Subjective(verbalizations from pt)
Objective(can be measured & observed)
Assessment (diagnosis based on the data)
Plan(what the caregiver plans to do)
Focus Note
D.A.R. =
Source Records
-admission section
-nursing section
-physician section
-respiratory section
-medication section
Charting by Exception
-shorthand method
-well-defined Standards of Practice
-Significant Findings
Case Management and Critical Pathways
-multidisciplinary approach
-standardized Plan of Care
Common Record Keeping Forms
-admission nursing history
-flow sheets/graphic records
-nursing discharge summary
Documentation in Nonacute Care
-home health care
-long-term care
Computerized Documentation
-specialized training for nurses
-decreases legibility problems
-authorization is needed for access
-computer-based personal record (CPR)
computer-based personal record (CPR) PAGE 495, Box 25-9
-PAGE 495, Box 25-9
-READ pg. 495
Computers Used in Nursing
-review previous nursing interventions
-print out / update current Nursing Plan of Care
-retrieve data from other disciplines
-obtain lab values
-order labs and diagnostic test
-communication with other disciplines
High Risk Errors in Documentation
-charting in advance – NEVER CHART IN ADVANCE
-incomplete patient admission assessment
-failure to follow agency’s standards or policies on documentation
-failure to document that physician was notified of a change in patient’s condition
-failure to document completely
-change of shifts
-telephone reports
-telephone or verbal orders
-transfer reports
-incident reports
Telephone or verbal orders
SEE handout: “Documenting Physician Orders”
Change-of-Shift reports
-avoid judgmental comments
-essential background information
-identify current health problems
-discharge plan
-priorities for oncoming nurse
Contents of Medical Record
-Face sheet
-Consent form
-Physician orders
-Medical history and physical exam
-progress notes
-summary of operation
-diagnostic results
-graphic records
-Medication administration record (MAR)
-Flow sheets
-Nurse’s notes
-Nursing admission assessment
-Nursing plan of care
-Discharge summary
Nursing Documents
-admission nursing assessment
-nursing care plan
-nurse’s notes
-graphic records
-medication records
-discharge summary
-flow sheets
Guidelines for Documentation

Guidelines for Documentation
-legible and neat writing
-use black ink
-proper use of grammar and spelling
-approved abbreviations
-chart only what you have done or observed
-record objective observations rather than interpretations
-record subjective data in quotes
-document refusal of medications or treatments, be sure to state reasons for refusal
-never squeeze information into a space because you forgot to chart it earlier – write “late entry” and the time it occurred
-avoid generalizations “seems uncomfortable today”
-avoid words that can mean different things to different readers – good, normal, sufficient, average
-do not erase or use correction fluid
-if you make an error, draw a single line through the error and write the word “void” and sign your initials.
-Date and time each entry
-Sign your first initial, last name, and title to each entry
-Do not leave blank spaces – draw a single line through all blank spaces
Accreditation agencies such as which of the following specify guidelines for documentation?
Joint Commission on accreditation of Healthcare Organizations (JCAHO)
Under the prospective payment system, hospitals are reimbursed a set dollar amt by Medicare for each:
Diagnosis-related Group (DRG)
A vital aspect of nursing practice is:
Documentation-which is anything written or printed within a client record. it is a vital aspect of Nursing Practice. Must be accurate, comprehensive and flexible enough to retrieve critical data, maintain quality and continuity of care, track client outcomes, and reflect current standards
Data recorded, reported, or communicated to other health care professionals are?
Confidential and must be protected
Clients frequently request copies of their medical records. The nurse understands?
They have the right to read those records
Critical pathways are care plans that:
Include key interventions and expected outcomes
Acuity records are designed to?
Determine hours of care and staff needed for a given group of clients in a 24 hr period
Ideally discharge planning begins?
At admission- there needs to be evidence of the involvement of the client and family members in the discharge planning process so that the client and family have the necessary info and resources to return home
In long-term care facilities the client is referred to as a (an)
A telephone order (TO)involves?
Clarification, accuracy and verification-the MD states a prescribed therapy over the phone to a RN. VO (verbal order) may be accepted when there is not a written order as in emergency situations.The nurse is responsible for writing the order on the MD's order sheet in the client's permanent record and signing it.
What are Critical pathways?
multidisciplinery care plans that include client problems, key interventions, and expected outcomes within an established time frame. promote integration of info so that each discipline has access to notes written by others