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16 Cards in this Set

  • Front
  • Back
List 6 reasons for the importance of documentation
1. Legal protection

2. Professional responsibility

3. Quality assurance

4. Education and/or research

5. Regulatory standards

6. Basis for care planning,
coordination and continuity of
List 4 desired outcomes of documenting
1. Reflects the nursing process

2. Charting follows the plan of care
(if not, reason are documented)

3. Legally sound documentation

4. Effective communication and
maintenance of confidentiality
List 4 factors that affect documentation
1. fax machines (not a good means
of communication and
jeopardizes confidentiality)

2. Computerized charting (not yet a
standardized language)

3. Accountability (chart your
actions only)

4. Time of documentation (try to
document immediately following
your actions or as soon as you
List the 5 types of documentation systems
1. Narrative

2. Problem-Oriented Medical
Records (POMR)

3. Source Records

4. Charting by exception (CBE)

5. Case Management or Critical
Identify the type of documentation based on the following points:

1. Client’s chart has separate
sections for each discipline

2. Advantage: caregivers can
locate proper section of record

3. Disadvantage: same problem
distributed throughout record
Identify the type of documentation based on the following points:

1. Specific to client conditions and
nursing care and primarily used
in psychiatric nursing

2. Advantages: flexible, strongly
conveys nursing interventions and
client responses

3. Disadvantages: redundancy,
unstructured, time consuming
Identify the type of documentation based on the following points:

1. Only document significant or
abnormal findings, all standards
of care are met unless otherwise

2. Advantages: reduces repetition
and ensures concise

3. Disadvantages: legalities, client
and family perspectives
CBE - Charting by Exception
Identify the type of documentation based on the following points:

1. Emphasizes pt problems,
consists of a data base, problem
list, plan of care and progress

2. Advantages: focus on the pt
problems, information and
interventions are clear, and it
reflects the nursing process

3. Disadvantages: time consuming,
negative connotation (focus on
the pt problems)
POMR - Problem-Oriented Medical
Identify the type of documentation based on the following points:

1. Identifies expected outcomes for
each day/type of care

2. Includes 3 types of charting
Critical Pathways
Critical pathway documentation includes 3 types of charting methods. List and define. (hint: D-A-R - define the letters)
1. S-O-A-P (-I-E-R)

S - subjective
O - objective
A - assessment
P - plan
I - intervention
E - evaluation
R - revision

2. P-I-E

P - problem
I - intervention
E - evaluation

3. D-A-R (focus charting)

D - data
A - assessment
R - pt response
List 5 guidelines for documentation
1. Use only black or blue ink

2. 24 hr clock (e.g. 2200 hrs is 10

3. Chronological order

4. Must be legible

5. Use approved terminology and
List the 7 things you should never chart
1. Avoid using labels to describe
your patient's behavior.

2. Don't refer to staffing problems.

3. Refrain from mentioning that an
incident report has been filed.

4. Don't try to explain a mistake or
use words like "accidentally"

5. Avoid airing "dirty laundry."

6. Never chart that you've
"informed" a colleague of an
event if you really only
mentioned it.

7. Never refer to another patient by
Give 4 rules for charting defensively
1. Avoid labelling

2. Be specific

3. Eliminate bias

4. Keep neutral language
Which of the following should an incident report not include?

A. Patient response
B. Name of Dr. notified
C. Your name
D. Assessment of the patient
C. Your name
There are 4 means of communicating with colleagues upon work shift changes. What are they?
1. Face to face

2. Audio tape

3. Walking rounds

4. Written out
When calling a Dr. or changing a shift what protocol should be used? Explain

A. D-A-R
B. S-B-A-R
C. S-D-E-O
D. P-O-M-R
B. S-B-A-R
(situation, background, assessment, communication)