ATI Ch 5 (Josh) Flashcards
T/F: Factual Documentation should be objective?
False
It should be Objective and Subjective.
Subjective data should be identified as coming from the client
What should be included on each entry when documenting?
Date & Time
Should we include opinions when documenting?
no
only assessments, interventions, and evaluations
—— ——– show trends in vital signs, blood glucose, pain level, and other frequent assessments.
Flow charts
Using standardized forms that identify norms and allows selective documentation of deviations from those norms is an example of which Documentation Format?
Charting by Exception
What are the different types of Documentation Formats?
Flow Charts Narrative Documentation Charting By Exception Problem Oriented Medical Records Electronic Health Records
An effective change-of-shift report should:
- include significant objective info about client’s health problems
- include no gossip or personal opinion
- relate recent changes in meds, treatments, procedures, & the discharge plan
How soon should the provider sign a telephone or verbal prescription?
24 hrs
Steps to remember when taking verbal/telephone orders?
- have second nurse listen with you
- repeat it back to make sure it’s correct
- question it if it seems inappropriate
Should a nurse include an incident report in a client’s medical record?
NO
Do client’s have a right to read and obtain a copy of their medical record?
Yes
Which of the following should be included in a change-of-shift report?
a) client’s input & output for the shift
b) client’s blood pressure from prev. day
c) bone scan that is scheduled for today
d) medication routine from the MAR
c) bone scan
important b/ the nurse might have to modify the client’s care to accommodate leaving the unit
