Taylor - Fundamentals Of Nursing - Adn 1 Exam #3 Chapter 17 -Documenting

Front 1

Documentation is:

Back 1

the written or typed legal record of all pertinent interactions with the patient—
assessing,
diagnosing,
planning,
implementing, and
evaluating.

Front 2

The patient record is:

Back 2

a compilation of a patient’s health information.
The patient record is the only permanent legal document that details the nurse’s interactions with the patient and is the nurse’s best defense if a patient or patient surrogate alleges nursing negligence.

Front 3

Aim of Documentation is to be:

Back 3

Complete,
accurate,
concise,
current,
factual, and
organized
data communicated in a timely and confidential manner to facilitate care coordination and serve as a legal document.

Front 4

The content of the documentation should be entered in a :

Back 4

complete, accurate, concise, current,and factual manner and reflects the nursing process and your professional responsibilities.
Record patient findings (observations of behavior) rather than your interpretation of these findings.

Front 5

Documentation should avoid words such as:

Back 5

“good,” “average,” “normal,” or“sufficient,” which may mean different things to different readers.

Front 6

Documentation should avoid generalizations such as:

Back 6

“seems comfortable today.”
A better entry would be:
“on a scale of 1 to 10, patient rates back pain 2 to 3 today as compared with 7 to 9 yesterday; vital signs returned to baseline.”

Front 7

Documentation should Note problems as they occur in an:

Back 7

orderly, sequential manner;
record the nursing intervention and the patient’s response;update problems or delete as appropriate.

Front 8

Documentation should Chart:

Back 8

any precautions or preventive measures used.

Front 9

Document all medical visits and consultations of which other nurses should be aware, either because:

Back 9

of their impact on the patient or because of the nursing care the patient now requires.

Front 10

Document in a legally prudent manner.

Back 10

Know and adhere to professional standards and agency/institutional policy for documentation.

Front 11

Document the nursing response to questionable medical orders or treatment (or failure to treat).:

Back 11

Factually record the date and time the physician was notified of the concern and the exact physician response.
If this occurs by phone, have a second nurse listen to the conversation and cosign the note.
If a nurse administrator was contacted, document this.
Documentation should give legal protection to the nurse, other caregivers, the healthcare agency or institution, and the patient.

Front 12

Avoid the use of:

Back 12

stereotypes or derogatory terms when charting.

Front 13

Chart in a timely manner.

Back 13

Follow agency policy regarding the frequency of documentation and modify this if changes in the patient’s status warrant more frequent documentation.
Indicate in each entry the date and both the time the entry was written and the time of pertinent observations and interventions. This is crucial when a case is being reconstructed for legal purposes.

Front 14

Most agencies use military time:

Back 14

one 24-hour time cycle,
to avoid confusion between a.m. and p.m. times.

Front 15

Document nursing interventions as closely as possible to the time of their execution:

Back 15

The more seriously ill the patient, the greater the need to keep documentation current. Never leave the unit for a break when caring for a seriously ill patient until all significant data are recorded.

Front 16

Never document interventions before:

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carrying them out.

Front 17

Write a progress note for each of these instances:

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•Upon admission, transfer to another unit, and discharge.
•When a procedure is performed.
•Upon receiving a patient postoperatively or postprocedure.
•Upon communicating with physicians regarding critical patient information (e.g., abnormal lab value result).
•For any change in patient status.

Front 18

Check to make sure you have the correct chart before writing.

Back 18

•Chart on the proper form as designated by agency policy.

Front 19

Use standard terminology:

Back 19

only commonly accepted terms and abbreviations and symbols.

Front 20

Chart nursing interventions chronologically on consecutive lines.

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Never skip lines.
Draw a single line through blank spaces.
Date and time each entry.
Do not use dittos, erasures, or correcting fluids.
A single line should be drawn through an incorrect entry and words“mistaken entry” or “error in charting” should be printed above or beside the entry and signed. The entry should then be rewritten correctly.
identify each page of the record with the patient’s name and identification number.

Front 21

Students using patient records are bound professionally and ethically to keep in strict confidence all the information they learn by reading patient records. Actual patient names and other identifiers shouldnot be used in written or oral student reports.

Back 21

Actual patient names and other identifiers should not be used in written or oral student reports.
Patients have a moral and legal right to expect that the information contained in their patient health record will be kept private.

Front 22

All information about patients is considered private o rconfidential, whether:

Back 22

written on paper, saved on a computer,or spoken aloud.
This includes their names and all identifiers such as address, telephone and fax number, Social Security number, and any other personal information.
It also includes the reason the patient is sick or in the hospital, office, or clinic, the treatments he or she receives, and information about past health conditions.

Front 23

PHI

Back 23

patient's health information

Front 24

Patient records serve many purposes such as:

Back 24

communication with other healthcare professionals,
recording of diagnostic and therapeutic orders,
care planning,
quality-of-care reviewing,
research,
decision analysis,
education,
legal documentation,
reimbursement, and
historical documentation.

Front 25

the only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is:

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in a medical emergency when the physician/nurse practitioner is present but finds it impossible, due to the emergency situation, to write the order. The order must be given directly by the physician or nurse practitioner to a registered professional nurse or registered professional pharmacist,who receives, documents, and executes the order. Verbal orders may not be given, received, or executed under any other circumstances.

Front 26

A sample policy for verbal orders follows:
Step A:
The registered professional nurse or registered professional pharmacist who receives the verbal order will:

Back 26

:1.Record the orders in the patient’s medical record.
2.Read back the order to verify accuracy of the order.
3.Date and note the time the orders were issued during the emergency.
4.Record V.O. (verbal orders), the name of the physician or nurse practitioner who issued the orders, followed by the nurse’s own name and title.

Front 27

A sample policy for verbal orders follows:
Step B.
Immediately after the conclusion of the emergency, it is the responsibility of the physician or nurse practitioner who has issued the verbal orders to:

Back 27

1.Review the orders to ascertain whether they are correct.
2.Sign the orders with his or her name, title, and pager number.
3.Date and note the time he or she signs the orders.

Front 28

A sample policy for verbal orders follows:
Step C:
It is the responsibility of the unit secretary and/or the registered professional nurse to see that:

Back 28

the orders are transcribed according to procedure.

Front 29

TELEPHONE AND FAX ORDERS
Agency policy must be followed regarding telephone orders.

Back 29

Every telephone order should be repeated back to the physician to ensure that the order is correctly understood.
If you are unsure of an order given by phone, ask the physician to repeat it. Telephone orders must be transcribed on an orders heet; policy usually dictates that they be cosigned by the physician within a set time.
If a telephone order is judged to be inappropriate, another nurse should also listen to the order.
Fax orders are acceptable as long as they are legible and issued from a credentialed and privileged individual.
As always, if there are any concerns, the ordering physician should be contacted.

Front 30

TELEPHONE AND FAX ORDERS Sample policy follows:

Back 30

A.An attending physician or nurse practitioner who finds it necessary to issue orders via telephone should be referred to a house officer or, in the absence of a house officer, to a registered professional nurse or aregistered professional pharmacist.
B.If a registered professional nurse accepts the orders,he or she must:
1.Record the orders in the patient’s medical record.
2.Read the order back to the ordering practitioner to verify accuracy.
3.Date and note the time the orders were issued.
4.Record T.O. (telephone orders) and the full nameand title of the physician or nurse practitioner who issued the orders.
5.Sign the orders with name and title

(Example:“Demerol 100 mg IM now and q 4 hr p.r.n. for pain. T.O. James E. Walker, MD/Mary Pint, RN”).

Front 31

TELEPHONE AND FAX ORDERS
It is the responsibility of the physician or nurse practitioner dictating the orders to:

Back 31

sign them as soon as practical,with the exception of orders for: restraints,
narcotics,
anticoagulants, and
antibiotics-
which many policies dictate must be signed within 24 hours.
He or she must also note the date and time the order is signed.

Front 32

A source-oriented record is:

Back 32

one in which each health care group keeps data on its own separate form.
An advantage of the source-oriented record is that each discipline can easily find and chart pertinent data.
The main disadvantage is that data are fragmented, making it difficult to track problems chronologically with input from different groups of professionals.

Front 33

progress notes are:.

Back 33

Notes written to inform caregivers of the progress a patient is making toward achieving expected outcomes

Front 34

narrative notes are:

Back 34

Progress notes written by nurses in a source-oriented record that address:
routine care,
normal findings (findings that do not call for changes in the plan of care), and
patient problems identified in the plan of care.
They include a description of the status of the problem,
related nursing interventions,
patient responses, and
needed revisions to the plan of care.

Front 35

Problem-Oriented Medical Records

(POMR) - problem-oriented medical record

Back 35

The POMR is organized around a patient’s problems rather than around sources of information.
With POMRs, all healthcare professionals record information on the same forms.
The advantages of this type of record are that the entire healthcare team works together in identifying a master list of patient problems and contributes collaboratively to the plan of care.

Front 36

Problem-Oriented Medical Records

the major parts of the POMR are:

Back 36

the defined database,
problem list,
care plans,and
progress notes.

Front 37

Problem-Oriented Medical Records

The SOAPIE format

Back 37

Subjective data,
Objective data,
Assessment [the caregiver’s judgment about the situation],
Plan,
Intervention,
Evaluation
is used to organize data entries in the progress notes of the POMR.
Caregivers select numbered problems from the master list on the front of the patient record and then work up the problem -or “SOAPIE it”- on the progress sheet.
it is originated from the medical record. the PIE format has a nursing origin

Front 38

The PIE charting system:

Back 38

Problem
Intervention
Evaluation
This is unique in that it does not develop a separate plan of care.
The plan of care is incorporated into the progress notes in which problems are identified by number (in the order they are identified).
In this documentation system, a complete patient assessment is performed and documented at the beginning of each shift using preprinted fill-in-the-blank assessment forms (flow sheets).
One advantage of this system is that it promotes continuity of care. It also saves time because there is no separate plan of care.
The disadvantage of not having aformal care plan is that nurses need to read all the nursing notes to determine problems and planned interventions before initiating care.
the PIE format has a nursing origin

Front 39

The purpose of focus charting is:

Back 39

to bring the focus of care back to the patient and the patient’s concerns.
Instead of a problem list or list of nursing or medical diagnoses, a focus column is used that incorporates many aspects of a patient and patient care. The focus might be a patient strength, problem, or need. Topics that may appear in the focus column include:
patient concerns and behaviors,
therapies and responses,
changes of condition, and
significant events such as:
teaching,
consultations,
monitoring,
management of activities of daily living, or assessment of functional health patterns.

Front 40

Focus Charting
DAR Format

Back 40

The narrative portion of focus charting uses the Data, Action, Response (DAR) format . The principal advantage of focus charting is the holistic emphasis on the patient and the patient’s priorities.
Ease of charting is also cited as an advantage of focus charting because it is not required that each note incorporate data, action, and response.

Front 41

Charting by exception (CBE) is:

Back 41

a shorthand documentation method that makes us
only significant findings or “exceptions” to these standards are documented in narrative notes.
Benefits of this approach include:
decreased charting time (freeing more time for direct patient care),
a greater emphasis on significant data,
easy retrieval of significant data,
timely bedside charting,
standardized assessment,
greater interdisciplinary communication, better tracking of important patient responses,and
lower costs.

Front 42

Charting by Exception-CBE

A significant drawback to charting by exception is:

Back 42

its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing.

Front 43

Case Management Model

Back 43

The case management model promotes collaboration,
communication, and
teamwork among caregivers;
makes efficient use of time;
it clearly identifies those outcomes that select groups of patients are expected to achieve on each day of care.
One limitation of this model, however, is that it works best for “typical” patients with few individualized needs.
increases quality by focusing care on carefully developed outcomes.

Front 44

Case Management Model

COLLABORATIVE PATHWAYS

Back 44

Collaborative pathways(may also be called critical pathways or care maps) are used in the case management model.
The collaborative pathway specifies the plan of care linked to expected outcomes along a timeline.
the collaborative pathway is part of a computerized documentation system that integrates the collaborative pathway and documentation flow sheets designed to match each day’s expected outcomes.

Front 45

Case Management Model

VARIANCE CHARTING

Back 45

When a patient fails to meet an expected outcome or a planned intervention is not implemented in the case management model, this variance from the plan is documented.
The usual format for variance charting is:
the unexpected event,
the cause of the event,
actions taken in response to the event,and discharge planning, when appropriate.

Front 46

Computerized Documentation and Electronic Medical Records (EMR)

Back 46

comprehensive computer systems have revolutionized nursing documentation in the patient record in which the nurse:
1.Calls up the admission assessment tool on the computer screen and keys in patient data
2.Develops the plan of care using computerized care plans available for each North American NursingDiagnosis Association (NANDA)-approved diagnosis
3.Adds to the patient database as new data are identified and modifies the plan of care accordingly
4.Receives a work list showing the treatments,procedures, and medications necessary for the patient throughout the shift
5.Documents care immediately using the computer terminal at the patient’s bedside

Front 47

Computerized Documentation and Electronic Medical Records (EMR)

minimum data sets.

Back 47

These specific categories of information use uniform definitions to create a common language among multiple health-care data users.

Front 48

The nursing minimum data set is organized into three categories:

Back 48

•Nursing care elements (such as nursing diagnoses and interventions)
•Patient demographic elements (such as sex, date of birth,and ethnicity)
•Service elements (such as admission and discharge dates and expected payer for services)

Front 49

PHRs-personal health records

Back 49

The chief reason for creating a personal health record is to provide easy access to up-to-date, complete health information to assist in self-care and communication with providers.
These records contain the individual’s medical history, including diagnoses, symptoms, and medications.
Some patients are scanning in doctors’ notes, test results, CT images, and insurance information.
They may give health-care professionals passwords so they can log on, and the permission to share the record with other family members.

Front 50

Initial Nursing Assessment

Back 50

it provides a baseline for later comparisons as a patient’s condition changes.

Front 51

Kardex and Patient Care Summary

Back 51

The Kardex is recorded on a folded card and placed in a central Kardex file where it is easily accessible.
The plan is eventually placed in the patient’s health record.
The outside of the card (activity and treatment section) contains basic information such as
the patient’s profile,
admitting diagnosis, and
orders concerning:
activity levels,
diet,
vital signs,
diagnostic tests,
medications,and
other treatments and procedures.
The inside of the Kardex contains the nursing care plan specifying nursing diagnoses and health problems, related outcomes and nursing interventions, and special safety precautions.

Front 52

Flow sheets

Back 52

are documentation tools used to record routine aspects of nursing care.

Front 53

GRAPHIC (CLINICAL) RECORD

Back 53

The graphic sheet is a form used to record specific patient variables such as:
pulse,
respiratory rate,
blood pressure readings,
body temperature,
weight,
fluid intake and output,
bowel movements, and
other patient characteristics.

Front 54

24-HOUR FLUID BALANCE RECORD

Back 54

Forms are available to document the 24-hour intake and output of fluids for patients with special needs.

Front 55

MEDICATION RECORD

Back 55

The patient’s medication record must include documentation of all the medications administered to the patient (drug,dose, route, time),
the nurse administering the drug, and for some medications (e.g., analgesics),
the reason the drug was administered and i
ts effectiveness.

Front 56

24-HOUR PATIENT CARE RECORDS AND ACUITY CHARTING FORMS

Back 56

are often used to document routine aspects of nursing care efficiently throughout a 24-hour period.
When well designed,they enable nurses to quickly document the routine aspects of care that promote patient:
goal achievement,
safety, and
well-being.

Front 57

Discharge and Transfer Summary

Back 57

At the time a patient is discharged from care or transferred from one unit or institution or agency to another, a discharge summary should be written that concisely summarizes: the reason for treatment,
significant findings,
the procedures performed and treatment rendered,
the patient’s condition on discharge or transfer, and
any specific pertinent instructions given to the patient and family.

Front 58

Home Healthcare Documentation

OASIS

Back 58

The Outcome and Assessment Information Set, or OASIS,is a group of data elements that:
•Represent core items of a comprehensive assessment fo an adult home care patient
•Form the basis for measuring patient outcomes for purposes of outcome-based quality improvement (OBQI).
The OASIS is a key component of Medicare’s partnership with the home care industry to foster and monitor improved home healthcare outcomes.

Front 59

Long-Term Care Documentation

RAI

Back 59

helps staff gather definitive information on a resident’s strengths and needs, and addresses these in an individualized plan of care.
The RAI helps staff track changes in a resident’s status by evaluating resident goal achievement and making appropriate revisions in the plan of care.
The goal is to coordinate the efforts of the multidisciplinary team to ensure that residents achieve the highest level of functioning possible.

Front 60

REPORTING CARE

Back 60

Reporting is the oral, written, or computer-based communication of patient data to others.
Common methods for reporting among health practitioners, in addition to the patient record, include:
face-to-face meetings,
telephone conversations, messengers,
written messages,
audiotaped messages, and
computer messages.

Front 61

REPORTING CARE

SBAR

Back 61

SBAR Communication(Situation, Back-ground, Assessment, Recommendation) technique is a framework for communication between members of the healthcare team about a patient’s condition.
it is a “hand-off communication”, an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action. It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team.

Front 62

REPORTING CARE

SBAR stands for:

Back 62

•Situation—Communicate what is occurring and why the patient is being handed off to another department or unit.
•Background—Explain what led up to the current situation and put in context if necessary.
•Assessment—Give your impression of the problem.
•Recommendation—Explain what you would do to correct the problem.

Front 63

Change-of-Shift Reports

Back 63

A change-of-shift report is given by a primary nurse to the nurse replacing him or her or by the charge nurse to the nurse who assumes responsibility for continuing care of the patient.
The change-of-shift report might be given in written form or orally in a meeting , or it may be audio- or video-taped.

Front 64

Incident Reports

Back 64

An incident report,also termed a variance or occurrence report, is a tool used by healthcare agencies to document the occurrence of anything out of the ordinary that results in or has the potential to result in harm to a patient, employee, or visitor. These reports are used for quality improvement and should not be used for disciplinary action against staff members. They are a means of identifying risks.

Front 65

CONFERRING ABOUT CARE

Back 65

To confer is to consult with someone to exchange ideas or to seek information, advice, or instructions.
A nurse might consult with another nurse, such as when a primary care nurse consults with a nurse clinical specialist about a particular patient’s care.

Front 66

Consultation

Back 66

The process of inviting another professional to evaluate the patient and make recommendations to you about his or her treatment is called a consultation.

Front 67

Referral

Back 67

The process of sending or guiding the patient to another source for assistance is called a referral.

Front 68

Nursing Care Rounds

Back 68

Nursing care rounds are procedures in which a group of nurses visit selected patients individually, at each patient’s bedside.
The primary purposes of nursing care rounds are to:
gather information to help plan nursing care, to evaluate the nursing care the patient has received, and
to provide the patient with an opportunity to discuss his or her care with those administering it.

Front 69

nursing informatics

Back 69

is a specialty that integrates:
nursing science,
computer science, and
information science to manage and communicate:
data,
information,and
knowledge in nursing practice.