all about documentaion Flashcards
what is considered subjective documentation?
signs of what you see
what is considered objective documentation?
symptoms that the patient is experiencing
what is included in an accurate and complete report?
clients status including their signs and symptoms
nursing care rendered
administration of medication and treatments
client’s response and any contact with other health care workers
what is critical for continuity and risk reduction in documentation?
current status/needs
progress
therapies
consultations
education
discharge planning
documentation needs to be what?
factual
accurate
complete
current
organized
what are common formats of documentation?
narratives
problem-intervention-evaluation (PIE)
SOAP/SOAPIE/SOAPIER (subjective data, objective data, assessment, plan, intervention, evalution, revision)
DAR (data,action,response)
what are types of forms you can see documentation in?
nursing admission data forms
discharge summary
flow sheets and graphic sheets
medication administration records (MAR)
Kardex
what must a paper chart have and what can not be done on a paper chart?
Print or script in blue or black ink only
NO white-out, erasable ink, obligate, erasing
what type of information goes on flow sheets?
vital signs
intake and output
assessment
what exactly is a Kardex form of documentation?
not a permanent record
nurses personal notes of the patients staus
such as allergies, medical diagnoses/orders, and the activities permitted
Narratives or nurses progess notes contain what type of information?
patients condition/problems/complaints
interventions
patients response to interventions
achievement of outcomes
additional assessment
report given and report received
what are some components of good documentation?
WHO
WHAT
patients complaints
care you provided
assessment findings
WHEN
the time when you provided care
WHERE
where was treatment given or medication administered
HOW
how was treatment completed
how did resident tolerate the treatment
OUTCOME
outcome of procedure/treatment
what terms do you want to avoid during documenting?
accidentally
apparently
appears
assume
confusing
could be
may be
miscalculated
mistake
somehow
unintentionally
normal
good
bad
what are common mistakes made during documentation that lead to legal actions?
failing to record health information/drugs
failing to record nursing actions
failing to record medications that were given
failing to record drug reactions/or change patient condition
failing to write legible or complete
failing to document discontinued/refusal medication
failing to notify Dr., nurse, family and recording exact conversation
failing to record a late entry correctly
failing to record referrals
failing to record patient teachings
how do you correct an error whenever you are paper sharing or electronically charting?
put a single line through the entry and put initials
EMR
new entry, explain error and make sure the chart is right
what three things make a documentation factual?
objective data (all senses except taste)
descriptive
subjective (NO ASSUMPTIONS)(patient or family)
how can you make documentation accurate?
exact measurements
clear
understandable
standard abbreviations only
timed, dated with signature and title
correct spelling
how do you ensure a documentation is complete?
note any condition changes
(onset, duration, location, description, precipitating factors, behaviors)
do not leave blanks: use N/A instead
any and all communication with patient and family
what all aspects are included in documentation to make it current?
ASAP
time of occurence
military clock
never pre-time, pre-date, pre-chart
how would you organize documentation?
complete sentences are not needed
concise/clear
to the point and in chronological order
if a physician fails to respond to a page or order an intervention leaving a patient at risk what would you need to do?
pursue the chain of command and notify your direct supervisor
how would you record a providers orders/response to their intervention with the patient?
exact time you contacted the provider
try using exact words if possible
add if the provider is going to do a follow up visit and put exact time
instead of using descriptive words about a patients actions how would you document a situation?
you would document their exact behaviors
patients refusal, reason for refusal, and what you did about it
in a court of law
DOCUMENTATION NOT DOCUMENTED IS CARE THAT WAS NOT PROVIDED
