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21 Cards in this Set
- Front
- Back
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What is the purpose of documentation?
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-To support nursing actions & indicate client's condition
-Primary communication tool -Legal protection -Reimbursement -Education -Quality Assurance -Research -Historic and legal document -Decision analyi sis |
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What are the different types of documentation forms?
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-Progress notes
-Flow sheets -Graphic Records -Nursing care plans -Caremaps & critical pathways -Admission & Discharge |
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Which type of documentation form looks like a paragraph with sentences, but not necessarily full & complete sentences?
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Progress note
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Why is documentation important for legal protection?
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If you don't document it, you did't do it
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What are the different methods of documentation?
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-Traditional (source oriented client record)
-Problem Oriented Medical Record (POMR) ie SOAP -Narrative -Charting by exception [CBE] -Computerized charting |
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What is the best assessment of patient care?
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Nurses note
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True or false
Documentation should be a diary of your activities |
false
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True or false
Documentation should always be kept confidential |
true
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Should documentation include subjective information, objective information, or both?
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Both subjective and objective
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When charting something the patient said, what must you do?
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Use quotations
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Is it ok to use words such as: appears, seems, telerated well?
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No. Always be specific. Using nonspecific terms implies doubt about your knowledge.
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In most cases, when care or observations are not charted, what does it mean?
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It wasn't done
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What are the ABCs of documentation?
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Accuracy
Brevity Completeness |
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True or false
It is always necessary to write the word "patient" when documenting |
False
It is inferred that if you are writing in that particular patient's chart or records that you are referring to that specific patient |
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True or false
It's best to chart at the end of your shift |
False
Always chart as soon as possible after care/observations |
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True or false
You should always chart what you plan to do |
False
Never chart what you plan to do unless you are writing a care plan |
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True or false
Date & time sould be entered in the margin using a standard 12 hr clock |
False
use military time, 24 hr time |
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True or false
Your should never skip lines when documenting |
True
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Why is writing legibly so important?
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Questionable information implies doubt and suggests that you lack reasonable knowledge
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True or false
If you make a mistake, do not white out or erase; cross out and write ERROR. |
False
Put a single line through mistake and print "Mistaken Entry" or ME (if acceptable) above or next to mistake, enter correction, initial & date |
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What is important to remember regarding change of shift reports?
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-Face-to-face, taped, written, walking rounds
-Must provide significant info about client in a logical order -Should be factual and free from gossip and/or opinion -Utilize SBAR for hand off reports |
