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Professional Nursing 1 > Canadian Nurses of Ontario (CNO) - Practice Standards for Documentation > Flashcards

Canadian Nurses of Ontario (CNO) - Practice Standards for Documentation Flashcards

1
Q

What are the three standard statements for documentation?

A

Communication

Accountability

Security

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2
Q

What are expectations that contribute
to public protection?

A

Standards

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3
Q

What informs nurses of accountabilities and the public of what to expect from nurses?

A

Standards

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4
Q

What applies to all nurses regardless of their roles, job description or areas of practice?

A

Standards

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5
Q

What is an important component
of nursing practice and interprofessionally within the client health record?

A

Documentation

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6
Q

What is used to monitor a
client’s progress and communicate with other care providers whether paper,
electronic, audio or visual?

A

Documentation

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7
Q

What reflects the nursing care that is
provided to a client?

A

Documentation

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8
Q

Who’s practice standard explains the regulatory and legislative requirements for nursing documentation?

A

Canadian Nurses of Ontario (CNO)

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9
Q

What is each statement followed by to outline a nurse’s accountability when documenting and provide
guidance on applying the standard statements to a particular practice environment?

A

Indicators

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10
Q

Why Document?

Nursing documentation:

  • reflects the ___’s perspective
  • identifies the ___
  • promotes continuity of ___ by allowing other partners in care to access the
    information
A

client

caregiver

care

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11
Q

Why Document?

Nursing documentation:

  • communicates to all health care providers the
    plan of care, the assessment, the interventions
    necessary based on the client’s ___ and the
    effectiveness of those interventions
A

history

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12
Q

Why Document?

Nursing documentation:

  • is an integral component of interprofessional
    documentation within the client record
  • demonstrates the nurse’s commitment to
    providing safe, effective and ethical care by
    showing ___ for professional practice
    and the care the client receives, and transferring knowledge about the client’s health history
A

accountability

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13
Q

Why Document?

Nursing documentation:

  • demonstrates that the nurse has applied within
    the ___ nurse-client relationship the
    nursing knowledge, skill, and judgment required
    by professional standards regulations
A

therapeutic

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14
Q

Why Document?

Whether documenting for individual clients, or for
groups or communities, the documentation should
provide a clear picture of:

  • ___ or ___ of the client or group
  • nurse’s ___ based on the needs assessment
  • ___ and evaluation of those ___
A

needs, goals

actions

outcomes

actions

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15
Q

Why Document?

Data from documentation has many purposes:

  • ___ professional practice as
    part of quality improvement processes
  • determine the ___ and services the client required or that were provided
  • nurses can review outcome information to ___
    on their practice and identify knowledge gaps that can form the basis of learning plans
A

evaluate

care

reflect

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16
Q

Why Document?

Data from documentation purposes in nursing research:

  • assess nursing ___ and evaluate client outcomes
  • identify care and documentation issues
  • advance ___-based practice
A

interventions

evidence

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17
Q

Why Document?

Nurses are required to make and keep ___of
their professional practice.

A

records

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18
Q

Why Document?

As regulated health care professionals, nurses are accountable for ensuring that their documentation is ___ and meets the College’s practice standards.

A

accurate

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19
Q

Why Document?

Failing to keep records as required, falsifying a record, signing or issuing a document that the member knows includes a false or misleading statement, and giving information about
a client without consent, all constitute professional
___ under the Nursing Act, 1991.

A

misconduct

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20
Q

Why Document?

What may be accessed in College
investigations and other legal proceedings?

A

Documentation

21
Q

Which diagram illustrates how the nursing profession, organizational environment, and self-regulatory framework within which nurses practise work together to support the client to obtain and/or maintain optimal functioning?

A

The Inter-Relationships that Support Clients through Documentation

22
Q

The Inter-Relationships that Support Clients through Documentation

Which support area includes College’s fact sheets’ and practice standards and guidelines supporting nurses in the provision of safe, ethical, and effective care?

A

College of Nurses of
Ontario

23
Q

The Inter-Relationships that Support Clients through Documentation

Which support area includes nursing organizations supporting nurses with policies,
procedures, and decision support tools?

A

Organizational

24
Q

The Inter-Relationships that Support Clients through Documentation

Which support area is the framework that acknowledges nurses as accountable to the practice standards that the College sets?

A

Self-
Regulatory

25
Q

The Inter-Relationships that Support Clients through Documentation

A
26
Q

Standard Statements and Indicators

What do the three standard statements and corresponding indicators describe for nurses when documenting?

A

Accountabilities

27
Q

Standard Statements and Indicators

What describes broad principles
that guide nursing practice?

A

Standard Statements

28
Q

Standard Statements and Indicators

What can help nurses apply the
standard statements to their particular practice
environment?

A

Indicators

29
Q

Standard Statements and Indicators

Which standard statement ensures that documentation presents an accurate, clear, and comprehensive picture of client needs, nurse interventions, and client outcomes?

A

Communication

30
Q

Standard Statements and Indicators

Which standard statement does a nurse meet with the following indicators?:

  • ensuring that documentation is a complete record
    of nursing care provided and reflects all aspects
    of the nursing process, including assessment,
    planning, intervention (independent and
    collaborative) and evaluation
  • documenting both objective and subjective data
  • ensuring that the plan of care is clear, current,
    relevant and individualized to meet the client’s
    needs and wishes
A

Communication

31
Q

Standard Statements and Indicators

Which standard statement does a nurse meet with the following indicators?:

  • minimizing duplication of information in the
    health record
  • documenting significant communication with
    family members/significant others, substitute
    decision-makers and other care providers
  • ensuring that relevant client care information
    kept in temporary hard copy documents (such as
    kardex, shift reports or communication books)
    is captured in the permanent health record
A

Communication

32
Q

Standard Statements and Indicators

Which standard statement is describe in the following example?:

When the electronic system is unavailable,
the nurse ensures that information captured
in temporary documents is entered in the
electronic system when it becomes available again.

A

Communication

33
Q

Standard Statements and Indicators

Which standard statement does a nurse meet with the following indicators?:

  • providing a full signature or initials, and
    professional designation (RPN, RPN[Temp], RN,
    RN[Temp] or NP) with all documentation
  • providing full signature, initials and designation
    on a master list when initialling documentation
  • ensuring that hand-written documentation is
    legible and completed in permanent ink
A
34
Q

Standard Statements and Indicators

Which standard statement does a nurse meet with the following indicators?:

  • using abbreviations and symbols appropriately by
    ensuring that each has a distinct interpretation
    and appears in a list with full explanations
    approved by the organization or practice setting
  • documenting advice, care or services provided
    to an individual within a group, groups,
    communities or populations (for example, group
    education sessions)
  • documenting the nursing care provided when
    using information and telecommunication
    technologies (for example, providing telephone
    advice)
A
35
Q

Standard Statements and Indicators

Which standard statement does a nurse meet with the following indicators?:

  • documenting informed consent when the nurse
    initiates a treatment or intervention authorized
    in legislation
  • advocating for clear documentation policies and
    procedures that are consistent with the College’s
    practice standards
A
36
Q

Standard Statements and Indicators

Nurses are ___ for ensuring their documentation of client care is accurate, timely, and complete.

A

accountable

37
Q

Standard Statements and Indicators

Which standard statement does a nurse meet with the following indicators?:

  • documenting in a timely manner and completing
    documentation during, or as soon as possible
    after, the care or event
  • documenting the date and time that care was
    provided and when it was recorded
  • documenting in chronological order;
A

Accountability

38
Q

Standard Statements and Indicators

Which standard statement does a nurse meet with the following indicators?:

  • indicating when an entry is late as defined by
    organizational policies
  • documenting at the next available entry space,
    and not leaving empty lines for another person
    to add documentation (when using paper
    documentation forms)
A

Accountability

39
Q

Standard Statements and Indicators

If there are empty lines, the nurse should draw a line from the end of the entry to the ___.

When using an electronic system, the nurse should refrain from leaving a ___ in a free-flow text box.

A

signature

space

40
Q

Standard Statements and Indicators

Which standard statement does a nurse meet with the following indicators?:

  • correcting errors while ensuring that the original
    information remains visible/retrievable
  • never deleting, altering or modifying anyone
    else’s documentation
  • enabling a client to add his or her information to
    the health record when there is a disagreement
    regarding care
A

Accountability

41
Q

Standard Statements and Indicators

Which standard statement does a nurse meet with the following indicators?:

  • documenting when information for a specific
    time frame has been lost or cannot be recalled
  • indicating clearly when an entry is replacing lost
    information
A

Accountability

42
Q

Standard Statements and Indicators

Which standard statement does a nurse meet with the following indicators?:

  • ensuring that documentation is completed
    by the individual who performed the action
    or observed the event, except when there is a
    designated recorder, who must sign and indicate
    the circumstances (for example, a code situation,
    or instances when an electronic system has
    technical difficulties and someone else enters the
    information when the system becomes available
    again)
A

Accountability

43
Q

Standard Statements and Indicators

Which standard statement does a nurse meet with the following indicators?:

  • clearly identifying the individual performing
    the assessment and/or intervention when
    documenting
  • advocating at the nurse’s facility for clear
    documentation policies and procedures that are
    consistent with the College’s standards
A

Accountability

44
Q

Standard Statements and Indicators

Which standard statement ensures nurses safeguard client health information by maintaining confidentiality and acting in accordance
with information retention and destruction policies and procedures that are consistent with the
standard(s) and legislation?

A

Security

45
Q

Standard Statements and Indicators

Which standard statement does a nurse meet with the following indicators?:

  • ensuring that relevant client care information is
    captured in a permanent record
  • maintaining confidentiality of client health
    information, including passwords or
    information required to access the client health
    record
  • understanding and adhering to policies, standards
    and legislation related to confidentiality
A

Security

46
Q

Standard Statements and Indicators

Which standard statement does a nurse meet with the following indicators?:

  • accessing only information for which the nurse
    has a professional need to provide care
  • maintaining the confidentiality of other clients
    by using initials or codes when referring to
    another client in a client’s health record (for
    example, using initials when quoting a client’s
    roommate)
  • facilitating the rights of the client or substitute
    decision-maker to access, inspect and obtain
    a copy of the health record, unless there is a
    compelling reason not to do so (for example, if
    disclosure could result in a risk of serious harm to
    the treatment or recovery of an individual)
A

Security

47
Q

Standard Statements and Indicators

Which standard statement does a nurse meet with the following indicators?:

  • obtaining informed consent from the client or
    substitute decision-maker to use and disclose
    information to others outside the circle of care
  • using a secure method such as a secure line
    for fax or e-mail to transmit client health
    information (for example, making sure the fax
    machine is not available to the public)
  • retaining health records for the period the
    organization’s policy and legislation stipulates
    when required by the nurse’s role (for example, in
    independent practice)
A

Security

48
Q

Standard Statements and Indicators

Which standard statement does a nurse meet with the following indicators?:

  • ensuring the secure and confidential destruction
    of temporary documents that are no longer in
    use
  • advocating for clear documentation policies and
    procedures that are consistent with the College’s
    standards
A

Security

49
Q
A

Professional Nursing 1 (6 decks)

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