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12 Cards in this Set
- Front
- Back
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Discuss the purpose of the clients health care record.
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-Communication
-Education -Legal documentation -Quality assurance- chart audits -Reimbursement -Research |
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Discuss legal guidelines for documentation- Confidentiality.
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-Never leave in public areas
-Never remove client information from facility -Dispose of confidential papers properly |
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Discuss legal guidelines for documentation- Incident reports.
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-Completed by staff who witnessed or found the incident
-Not included in your notes -For internal record only (not discoverable) |
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Describe five quality guidelines for documentation and reporting.
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Accurate, concise, complete, specific, and timely.
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What are the issues related to computerization in documentation?
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-Do not display data where others can see it.
-Correct errors as protocol -Never leave terminal unattended after you log on. -Do not give password or log on info to anyone. |
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What is the purpose of a change of shift report?
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The purpose of change of shift report is to alert the next caregiver about the clietns status or recent changes in the clients condition, and to discuss planned activities, tests, procedures, or concerns that require follow up.
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What are the different documation systems for recording client data?
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-Source Oriented records
-Problem oriented records |
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Describe source oriented record.
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Members of each discipline record their findings.
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Describe problem oriented record.
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The POR consists of four compoinents: Database, Problem list, plan of care, progress notes.
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What are the essential compoinents of the clients chart?
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-Basic assesment data
-In-depth assesment of any abnormalities -Nursing actions taken -patient response to these actions -Patient progress towards goals of plan of care -education provided -discharge needs/care/instrustions. |
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What are the different types of charting?
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-Narrative charting
-Block charting -SOAP -PIE -FOCUS/DAR -Charting by exception -Computer assisted charting -Computerized charting |
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When should a nurse question an order?
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-Any order a patient questions
-Any order if the patients condition has changed -Standing orders if inexperienced and have questions -Ambiguous order -You can clarify/discuss an order with your supervisor. |
