Nursing Documentation & Reporting

Front 1

is the written or printed record of a client's care

Back 1

documentation

Front 2

documentation is the essential data for...

Back 2

revision or continuing of care

Front 3

this: must be maintained through out the entire nursing documentation process

Back 3

confidentiality

Front 4

Governs all information are management, including reimbursement, security, and client records. prevents misuse of clients information

Back 4

HIPPA- health insurance portability & accountability act

Front 5

this act allows clients to review their personal health records

Back 5

HIPPA

Front 6

The only people who may have access to the records include:

Back 6

health team members directly involved with the pt's care
accreditation reviewers
certification reviewers
licensing organizations
performance improvement monitors
peer reviewers
Medicare and insurance company reviewers
researchers and teachers
lawyers and judges

Front 7

what is the purpose of documentation?

Back 7

to communicate care
legal documentation (proof care was given)
for financial billing
education
research

Front 8

Chronological account of clients care & response to care

Back 8

narrative documentation

Front 9

this documentation system is more traditional than others.

Back 9

Narrative

Front 10

This documentation system is in story like format

Back 10

narrative

Front 11

this documentation system is a structer that emphasizes the clients identified problems and progress

Back 11

problem oriented

Front 12

problem oriented documentation includes

Back 12

database, problem list, plan of care, progress notes, and discharge summary

Front 13

SOAP

SOAPIER

Back 13

subjective data
objective data
assessment
plan

implementation
evaluation
revision

Front 14

this documentation system requires only deviation from basline

Back 14

charting by exception

Front 15

charting by exception documents

Back 15

abnormal finding

Front 16

documentation system that uses:
nursing standard plan of care
nursing flow sheets
graphic record
pt teaching record
discharge note
progress ntoes

Back 16

CBE

Front 17

Organizes information according to clients problems

Back 17

problem intervention evaluation

Front 18

uses daily assessment flow sheet
and progress notes include pie

Back 18

problem intervention evaluation

Front 19

PIE

Back 19

problem
intervention
evaluation

Front 20

this is a newer method of documenting client care

Back 20

electronic charting

Front 21

fast and easy retrieval of information common in this system

Back 21

electronic charting

Front 22

in documentation never ever ever do this...ever!

Back 22

erase

Front 23

who do you chart for?

Back 23

yourself and yourself only

Front 24

used for any unusual occurrence

Back 24

incident reports

Front 25

incident reports must include

Back 25

witness name
notification of physicain

Front 26

do not include incident reports innnnn

Back 26

the pt's chart

Front 27

incident reports are housed with in

Back 27

risk managment

Front 28

juries only know about the quality of your nursing care by

Back 28

your documentation