ATI - Chapter 5 Flashcards
The chart of medical record is the _____ of care.
legal record
The medical record is a confidential, permanent, and _____ document that is admissible in court.
legal
Nurses are legally and ethically responsible for ensuring _____.
confidentiality
Only health care providers who are involved directly in a client’s care may access that client’s _____.
medical record.
Nurses document the care they provide as documentation or charting and it should reflect the nursing ____.
process
There is a rapidly growing trend for maintaining medical records _____, which creates challenges in protecting the privacy and safety of health information.
electronically
Information to document includes assessments, medication administration, nursing actions, treatments and responses, and ______.
client education
______ is a standard for many accrediting agencies, including The Joint Commission mandates the sue of computerized databases to expedite the accreditation process.
documentation
Health care facilities use the ________ for budget management, quality improvement programs, research, and many other endeavors.
computerized data
Purposes for medical records include communication, legal documentation, financial billing, education, research, and _____.
auditing
The purpose of reporting is to provide continuity of care and enhance communication among all team members who provide care to the same clients, thus promoting _____.
client safety
Nurses should conduct reporting in a ____ manner.
confidential
Elements of documentation
factual - objective and subjective data
accurate and concise
complete and current
organized
Nurses should document ____ as direct quotes, within quotation marks, or summarize and identify the information as the client’s statement.
subjective data
Subjective data should be supported by objective data so charting is as _____ as possible.
descriptive
_____ should be descriptive and should include what the nurse sees, hears, feels, and smells.
objective data
Document without derogatory words, judgments, or opinions. Document the client’s behavior ______. Instead of writing “client is agitated”, write “client pacing back and forth in his room, yelling loudly.”
accurately.
Document facts and info precisely (what the nurse sees, hears, feels, smells) without any _____ of the situation.
interpretations
Unnecessary words and irrelevant details should be _____ in documentation.
avoided
Exact measurements establish _____. Only abbreviations and symbols approved by the Joint Commission and the facility are acceptable.
accuracy
Document information that is comprehensive and ______. Never pre-chart an assessment, intervention, or evaluation.
timely
Communicate information in a logical ______.
sequence
Begin each entry with the date and ____.
time
Record entries legibly, in non-erasable black ink, and do not leave _____ in the nurses’ notes.
blank spaces
Do not use _____, erase, scratch out, or blacken out errors in the medical record. Make corrections promptly, following the facility’s procedure for error correction.
correction fluid
Sign all documentation as the facility requires, generally with ______.
name and title
Documentation should reflect assessments, interventions, and evaluations, not personal opinions or _______ about client or other care care professionals’ care.
criticism
_____ show trends in vital signs, blood glucose levels, pain level, and other frequent assessments.
flow charts
_____ records information as a sequence of events in a story like manner
narrative documentation
________ uses standardized forms that identify norms and allows selective documentation of deviations from those norms
charting by exception
_______ are organized by problem or diagnosis and consist of a database, problem list, care plan, and progress notes.
problem oriented medical records
_______ are replacing manual formats in many settings.
electronic health records
Advantages include standardization, accuracy, confidentiality, easy access for multiple users, providing ease in maintaining ongoing health record of client’s condition, and rapid acquisition and ______________
transfer of clients information
Challenges of ______ include learning the system, knowing how to correct errors, and maintaining security.
electronic medical records
Documentation rules and formats are similar in electronic health records to those for ______.
paper charting
Nurses give the ______ report at the conclusion of each shift to the nurse assuming responsibility for the clients. Formats include face to face, audiotaping, or _____ during walking rounds in each client’s room (unless the client has a roommate or visitor)
change of shift
presentation
An effective end of shift report should include significant objective information about the client’s ______. Proceed in a logical sequence. Include not gossip or personal opinion. Relate recent changes in medications, treatments, procedures, and the ______.
health problems
discharge plan
____ reports are useful when contacting the provider or other members of the interprofessional team.
telephone
During the telephone reports it is important to have all the data ready prior to contacting any member of the interprofessional team. Use a professional demeanor. Use _____, relevant, and accurate information. Document the name of the person who made the call and to whom the information was given; the time, _____ and the instructions or information received during the report.
exact
content of the message
Telephone or _______ are best to avoid, but they are sometimes necessary during emergencies and at unusual times.
verbal prescriptions
During telephone or verbal prescriptions have a _____ nurse listen to a telephone prescription. Repeat it back, making sure to include the medication’s name (spell if necessary), dosage, time, and route. _______ any prescription that seems inappropriate for the client.
second
question
With telephone or verbal prescriptions make sure the provider signs the prescription in person within the time frame the facility specifies, typically ____.
24 hours
______ or hand off reports should include demographic info, medical diagnosis, providers, and overview of health status (physical, psychosocial), plan of care, recent profess, any alterations that might become an urgent or emergent situation, directives for any assessments or client care essential within the next few hours, most recent vital signs, medications and last does, allergies, diet, activity, specific equipment or adaptive devices, advance directives and resucitation status, discharge plan, family involvemtn, and health care proxy.
transfer (hand-off) reports
____ or unusual occurrences are an important part of a facility’s quality improvement plan.
incident reports
An incident is the occurence of an accident or an unusual event. Examples of incidents are medication errors, falls, omission of prescription and _____.
needlesticks
In incident reports document facts without judgement or opinion and do not refer to to an incident report in a client’s _____.
medical record
Incident reports contribute to changes that help improve health care _____.
quality
Mandatory adherence with the health Insurance Portability and Accountability Act of 1996 (HIPPA) began in 2003 to help ensure the ________ of health information.
confidentiality
A major component of HIPAA, the Privacy Rule, promotes the use of standard methods of maintaining the privacy of protected health information (PHI) among health care _____.
agencies
It is essential for nurses to be aware of clients’ rights to privacy and confidentiality. Facilities’ policies and procedures help ensure adherence with _____.
HIPAA regulations
The Privacy rule requires that nurses protect all written and verbal communication about clients. Components of the _____.
privacy rule
Only health care team members directly responsible for a client’s care may access that client’s record. Nurses may not share information with ______ or staff not caring for the client.
other clients
Clients have a right to ____ and _____ a copy of their medical record.
read and obtain
Nurses may not ______ any part of a medical record except for authorized exchange of documents between facilities and providers.
photocopy
Staff must keep medical records in a secure area to prevent inappropriate _____ to information. They may not use public display boards to list client names and diagnoses.
access
Electronic records are password protected. The public may not view them. Staff must use only their own ______ to access information.
access
Nurses must not disclose clients’ information to unauthorized individuals or family members who request it in person or by _____ or email.
telephone
Many hospitals use a code system to identify those individuals who may receive information about certain ____.
clients
Communication about a client should only take place in a private setting where unauthorized individuals can give the ____.
code
Communication about a client should only take place in a private setting where unauthorized individuals cannot _____.
overhear it
To adhere to HIPAA regulations, each facility has specific policies and procedures to monitor staff adherence, technical protocols, computer privacy, and ____.
data safety
