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23 Cards in this Set

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What are the standards of Documentation ?
1. Set by JACHO
2. It requires Assessment of physical, psychosocial, environmental, self-care, educational and DC components
3. Show use of NP
4. Show pain mgmt.
5. Document interdisciplinary interaction
Which of the 4 involves hospice care?
LTC facilities
What are two important items to be contained in Discharge Charting?
Pt. / family education and referrals to community services
What are 4 examples of skilled services?
IV anti-bx therapy, wound care, hospice care, PT
How can the chart be used as a legal document? from SDM p. 46
1. It communicates objective information to the healthcare team.
2. It assists supervisory personnel in evaluating the staff's performance on a daily basis for patients.
3. It provides a permanent record for future reference in the event of litigation or prosecution.
What are 4 examples of community-based care?
Home (health)
Ambulatory care center
Rehab Center
LTC / long term care facilities
What are four purposes of charting?
To know for test from notes:
Legal, Show pt. progress or lack of progress/Evaluation, Communication between staff on patient care, Provides continuity of care.
It also shows the safety of patient, shows completiion of patient tasks by staff, and documents changes in patient's condition
Which of the following is not an unskilled service?
Bathing, Shopping, Respiratory Therapy, Meals on Wheels
Respiratory Therapy
Providing baseline information is the purpose of ?
Admission Charting / Information; it does this by obtainig a nursing hx of the patient prior to coming to the facility / or what brought them to the facility.
In which of the three charting systems is it necessary to read the whole chart in order to obtain a complete picture of the patient?
Source-oriented charting
When you chart in the medical record, you are to write like a _______________?
reporter
Which charting system involves narrative charting?
Source-oriented
What other major components of charting are found in Iggy p. 16 ?
Write clearly and legibly
Do not erase or "white-out" information
Use one line through information to correct errors
Document significant information as soon as possible from when it happened
Time and date each entry in chart
Use black or blue ink only
DO NOT note in chart that an incident report has been written.
Use a ^ to add information in chart
Identify info as a late entry if you need to make it
If a highlighter is used to note a d/c'd order, make sure that the original can be read through it
Which of the three care systems (community-based, managed, or alternative) is focused on the quality of care and cost of care?
managed care
What are several major components of charting? from class notes...
Nursing Process
Precise measurements
Pain scale
Pt. states...
Admin. of meds. and Rxs
Prep. for tests with signed consents
Signature with title
NEVER document "pt. fell..."
DO NOT get even in the chart (with other staff)
Use only facility approved abbrev. / terms
BE specific, clear, precise
Use correct spelling
Leave no blank lines in chart
Cost effective is to Home (health) and Ambulatory Care Center as ______________ is to Managed Care.
Cost Containment
Which of the four areas of community-based care involves terminal care and respite care?
Home (health)
True or False:
One advantage of Problem-oriented charting is that it deals with the patient's status, not the location of the information
TRUE - the location of the information is Source-oriented charting.
True or False:
Community care centers only provide skilled services, not unskilled services.
FALSE ! They provide skilled and unskilled in HH and LTC facilities and skilled only in ambulatory care centers and rehab centers.
Which of the four is highly regulated by the federal gov't?
LTC facilities
In which of the three charting systems is repetition and duplication of information a problem?
Problem-oriented charting
In which of the three is downtime a problem and getting the information is easily retrievable?
Computer assisted charting
Give several examples of alternative care.
religion, relaxation, imagery, herbs, music, aromatherapy, acupuncture, massage therapy, yoga