Nursing 120- Test 3 - Documentation - Olol

Front 1

What is Documentation?

Back 1

Documentation is a WRITTEN, legal record of all pertinent interactions with the patient.
Nursing Documentation must be accurate and comprehensive.

Front 2

Guidelines for Documentation

Back 2

Policy Statements
Principles
Recommendations

Front 3

Purposes for Recording and Reporting Patient Care

Back 3

Communication
Quality Assurance
Reimbursement
Legal/Ethical
Research
Education

Front 4

Communication

Back 4

-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

Front 5

Quality Review

Back 5

-Audits of reports and records provide another way to evaluate the quality of patients’ care
-Example: JCAHO (Joint Commission Accreditation of Hospital Organization)

Front 6

Reimbursement

Back 6

-The Diagnosis-related groups (DRGs) have become the basis for establishing reimbursement for client care.
-Example: Reimbursement for Wound Care

Front 7

Legal/Ethical Obligations

Back 7

-Patient-related reports and clinical records are legal documents that can be used as evidence in courts of law

Front 8

Research

Back 8

-Data derived from patient reports and records are prime sources of information about patient characteristics and responses to interventions

Front 9

Education

Back 9

-Nursing students, medical students, and other disciplines use the record as a learning tool

Front 10

Poor communication Through Documentation

Back 10

-“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.”

Front 11

Guidelines for Quality Documentation and Reporting

*factol

Back 11

-factual
-accurate
-complete
-timely (current)
-organized
-legible

Front 12

Factual

Back 12

-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

Front 13

Accurate

Back 13

-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.)

Front 14

Complete

Back 14

-use of appropriate information
-use of essential information
-describing concise nursing care
-describing the client’s response

Front 15

“Administration of Narcotics”

Back 15

-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

Front 16

Current/Timely

Back 16

-helps avoid errors
-helps avoid forgetting information
-record medication administration and treatments
-record admission, and change in patient status

Front 17

Organized

Back 17

-systemic / systematic
-logical
-chronological flow

Front 18

Legible

Back 18

-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.

Front 19

Methods of Recording

Back 19

-Narrative Notes
-Problem-Oriented Medical Record (POMR)
-Source records
-Charting by exception
-Case Management and critical pathways

Front 20

Narrative Notes

Back 20

-Traditional Method
-A story format
-Repetitious information

Front 21

Problem-Oriented Medical Record (POMR)

Back 21

-provides Database
-problem list
-Nursing care plan
-Progress note: SOAP, PIE, Focus

Front 22

SOAP

Back 22

Subjective(verbalizations from pt)
Objective(can be measured & observed)
Assessment (diagnosis based on the data)
Plan(what the caregiver plans to do)

Front 23

PIE

Back 23

Problem
Intervention
Evaluation

Front 24

Focus Note

Back 24

D.A.R. =
Data
Action
Response

Front 25

Source Records

Back 25

-admission section
-nursing section
-physician section
-respiratory section
-medication section

Front 26

Charting by Exception

Back 26

-shorthand method
-well-defined Standards of Practice
-Significant Findings

Front 27

Case Management and Critical Pathways

Back 27

-multidisciplinary approach
-standardized Plan of Care

Front 28

Common Record Keeping Forms

Back 28

-admission nursing history
-flow sheets/graphic records
-kardex
-nursing discharge summary

Front 29

Documentation in Nonacute Care

Back 29

-home health care
-long-term care

Front 30

Computerized Documentation

Back 30

-specialized training for nurses
-confidentiality
-decreases legibility problems
-authorization is needed for access
-computer-based personal record (CPR)

Front 31

computer-based personal record (CPR) PAGE 495, Box 25-9

Back 31

Advantages:
-PAGE 495, Box 25-9
Disadvantages:
-READ pg. 495

Front 32

Computers Used in Nursing

Back 32

-review previous nursing interventions
-print out / update current Nursing Plan of Care
-retrieve data from other disciplines
-document
-obtain lab values
-order labs and diagnostic test
-communication with other disciplines

Front 33

High Risk Errors in Documentation

Back 33

-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

Front 34

Reporting

Back 34

-change of shifts
-telephone reports
-telephone or verbal orders
-transfer reports
-incident reports

Front 35

Telephone or verbal orders

Back 35

SEE handout: “Documenting Physician Orders”

Front 36

Change-of-Shift reports

Back 36

-avoid judgmental comments
-essential background information
-identify current health problems
-treatments
-teaching
-discharge plan
-priorities for oncoming nurse

Front 37

Contents of Medical Record

Back 37

-Face sheet
-Consent form
-Physician orders
-Medical history and physical exam
-consultations
-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

Front 38

Nursing Documents

Back 38

-admission nursing assessment
-nursing care plan
-nurse’s notes
-graphic records
-medication records
-discharge summary
-flow sheets

Front 39

Guidelines for Documentation








Guidelines for Documentation

Back 39

-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

Front 40

Accreditation agencies such as which of the following specify guidelines for documentation?

Back 40

Joint Commission on accreditation of Healthcare Organizations (JCAHO)

Front 41

Under the prospective payment system, hospitals are reimbursed a set dollar amt by Medicare for each:

Back 41

Diagnosis-related Group (DRG)

Front 42

A vital aspect of nursing practice is:

Back 42

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

Front 43

Data recorded, reported, or communicated to other health care professionals are?

Back 43

Confidential and must be protected

Front 44

Clients frequently request copies of their medical records. The nurse understands?

Back 44

They have the right to read those records

Front 45

Critical pathways are care plans that:

Back 45

Include key interventions and expected outcomes

Front 46

Acuity records are designed to?

Back 46

Determine hours of care and staff needed for a given group of clients in a 24 hr period

Front 47

Ideally discharge planning begins?

Back 47

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

Front 48

In long-term care facilities the client is referred to as a (an)

Back 48

Resident

Front 49

A telephone order (TO)involves?

Back 49

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.

Front 50

What are Critical pathways?

Back 50

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