Ch. 16 Documenting And Reporting (Week 5 Quiz) Flashcards
What is the goal of nursing documentation ?
To be a clear concise representation of a patients healthcare experience. It should be easily accessible and understandable by ALL members of the healthcare team
What are the 2 things to NEVER do when documenting?
- NEVER document actions of others as though you performed them. (What if they do a bad job? or forget steps? do you want to be responsible?)
- NEVER document before something is due (what if you forget to give the med? Patient then misses a dose because the next nurse thinks they got it.)
What are the ABC’s of documentation?
Hint: important factors in a health record
Accurate Bias-free (no personal feelings) Complete Detailed Easy to read Factual Grammatical Harmless (legally)
What is the purpose of the written record?
- to communicate between providers
- educational tool
- legal documentation of care
- quality improvement (working to make things better)
- research
- reimbursement
_______ ________ documentation is when varying disciplines chart separately (ie physical therapy, social work, dietician, discharge planning). It may lead to data being scattered or fragmented.
Source oriented documentation
Your shift is over and it is time to handoff your patient to the next shift. What are the 3 things you always do?
When documenting, narrate the last thing you did for the patient (and how the patient was when you left them), what needs to be done for the patient by the next nurse’s shift, and how the patient feels.
This type of documentation is organized around patients problems. It allows greater collaboration and REQUIRES all departments to work together and chart in shared notes.
Problem oriented records (POR)
What are the four components of POR’s?
DPPP
- Database: Demographic, H&P, Nsg Assessment and family&social history
- Problem list (pg 294 fig 16-1)
- Plan of care-provider orders+nursing care plan for addressing problems.
- Progress notes - organized according to problem list, each discipline charts in shared notes.
What are common types of charting?
Narrative PIE - Problem Intervention Evaluation SOAPIER Focus CBE - Charting By Exception FACT system Electronic entry
A _________ is when the patients experience is documented in chronological order (like a story). Info may be buried in the text and it’s difficult to track problems because it is long and disorganized. It does tracks patients changing status.
Narrative (narrative format)
SOAP(IER) is the most common type of charting that we use. What does this acronym stand for?
S: subjective data O: objective data A: assessment P: plan I: intervention E: evaluation R: revision
_______ charting views patient’s status from a positive perspective (versus problem oriented). You would use assessment data to evaluate patient care concerns, problems, or strengths. Usually three columns, 1)TIme and Date; 2)Problem being addressed; 3) DAR (data,action,response)
Focus charting
“Focus on the positive.”
What does the acronym FACT mean?
F: flow sheet
A: assessment
C: concise
T: timely entries
Why document the nursing admission assessment?
- To record baseline data and monitor change
2. Help forecast future needs
What are Flow sheets used for?
Hint: RDTIO
- Record routine aspects of care (the flow of care)
- Document assessments (organized according to body systems - the assessment flow)
- Track patient response to care (wound care, pain, IVs)
- Intake&Output records (literally the flow of fluids in and out)
What is a graphic record used for?
It is used to record vital signs.
COMBINED charting and care plan form. Maps out day by day (from admission to discharge): patient goals, outcomes, interventions, and treatments for a specific diagnosis or condition.
Laboratory work, diagnostic testing, medications, and therapies included in the pathway.
IPOC - Integrated Plans of Care
Passage of vital information related to the patient’s status/plan of care; Informing other caregivers about the clients condition; we use SBAR. This info is shared between nurses or between nurses and doctors. This can take place over the phone or in person, on rounds, or at the bedside.
reporting
This report is a formal record of an unusual occurrence or accident (ie pt injury, complaint or mistake was made by RN). It is not part of patient health record.
Occurrence (Incident) Reports
Serves quality improvement. We are told to report all errors: even if there was no adverse impact on patient.
Use objective terms and quote everyone involved.
DO NOT place blame or draw conclusions!
What is a hand-off report? What is the purpose of a hand-off report?
A hand-off report is aka change-of-shift report. It’s purpose is to alert the next caregiver about the client’s status or recent changes in the clients condition, discuss planned activities, tests procedures, or concerns that require follow-up. May be: verbal, through walking rounds, or auditor recorded (not the preferred method)
What is one thing you NEVER do as a nursing student?
NEVER interrupt another nurse!!!!! (Friendly reminder :))
Ever ever ever ever!!!
(…well unless a patient is coding, I think they might forgive you)…
What format do you use for a Hand-off report?
SBAR or PACE
What does it mean to keep it CUBAN?
Confidential Uninterrupted Brief Accurate Named Nurse -add full name to the report
What is the purpose of a transfer report? What information is included?
Transfer reports are given when a pt is transferred from unit to unit or from facility to facilty to ensure accurate and thorough communication between healthcare professionals/facilities.
Include: -Your contact info -Pt. demographics, diagnosis, reason for transfer, Code or NO code status -Family contact info -Summary of care -Current status -Presence of wounds -Always ask if the receiver has questions
What information should you include in a discharge summary?
Time of departure and method of transportation
Name and relationship of person(s) accompanying pt. at discharge
Condition of client
Teaching conducted
Discharge instructions
Follow ups or referrals
You are receiving an order verbally and then by telephone. What should you do during both the verbal order and then telephone order?
REPEAT the order back for clarification. It is mandatory that you clarify any order!!!!!
Is it okay to document patient info weeks later?
NO. Document legibly and as soon as possible
What is the timeline for documenting Long Term Care?
Minimum data set (MDS) for resident assessment and care screening must be completed within 14 days of admission and updated every 3 months.
If you can not get in contact with the primary care provider what do you do?
Record any attempts you have made to contact the primary care provider
If you use restraints on a patient what do you include in the documentation?
Chart use of restraints, including reason for use, type of restraints, and frequent checks of the pt.
If you made an occurrence (incident) report, do you need to include this information in the chart.
NO! Do not chart that you have filled out an incident report.
If you make a mistake when charting what steps should you take?
Draw a single line through the entry and place your initials next to the change
Is it okay for a patient to refuse treatment of medication?
YES. Chart any patient refusal of treatment or medication. Record on the medication administration record in narrative form an do not leave blank lines.
