Ch. 18: Documenting and Reporting-MJ Flashcards

1
Q

The act of recording patient status and care in written or electronic form or in combination of the two forms

A

Documenting

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2
Q

What other terms are considered documenting?

A

Documenting, reporting, charting

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3
Q

What should be included in the documentation?

A
Health history
Exams
Tests
Treatment
Outcomes
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4
Q

What is the purpose of documentation?

A

To provide continuity of care among all team members who provide care to the same patient

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5
Q

Documentation should always reflect the _____

A

Nursing process

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6
Q

Documentation provides communication between ____-

A

Providers

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7
Q

Documentation does ____ of care

A

Continuity

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8
Q

Documentation is an ____ tool and can be used during ____

A

Education tool; research

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9
Q

Documentation give a _____ of care

A

Legal document

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10
Q

T/F: Documentation provides quality improvement and reimbursement.

A

True

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11
Q

What are the 4 advantages of written documentation?

A
  • Familiar
  • Does not require a large database networks and is secure to function
  • Not dependent on power/electricity
  • Inexpensive
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12
Q

What are the disadvantages to written documentation?

A
  • Access may be delayed
  • Retrieving info may be slow
  • Time consuming
  • High risk patient error
  • Storage is expensive
  • Difficult to protect confidentiality
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13
Q

What are the advantages to electronic documentation?

A
  • Communication is improved among health providers
  • Improved access to info
  • Saves time
  • Improves the quality of care
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14
Q

What are the disadvantages to electronic documentation?

A
  • Expensive
  • Electrical issues
  • Difficulties with learning
  • Lack of integration
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15
Q

What are some examples of common types of charting?

A

Narrative, PIE, SOAPIER, Focus, Charting by Exception, FACT system, and electronic entry format

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16
Q

Which charting type tells the story of the patient?

A

Narrative

17
Q

What is the advantage to narrative charting?

A

Helps set a goal for the patient and tracks the clients health status

18
Q

What are the disadvantages to narrative charting?

A

Time consuming, disorganized, contain multiple entries, must read the entire note of the client, and does not readily identify problems and trends

19
Q

What does PIE stand for?

A

Problem intervention evaluation

20
Q

What are the advantages to PIE charting?

A

Eliminates the need for a separate care plan and provides a nursing focus rather than a medical focus record

21
Q

What is the disadvantage to PIE?

A

Does not document the planning portion of the nursing process

22
Q

What does SOAP(IER) stand for?

A
Subjective data
Objective data
Assessment
Plan
Intervention
Evaluation
Revision
23
Q

Advantages of SOAPIER: To shift the focus from the patient to the ___, promoting a medical model instead of the _____

A

Disease, nursing process

24
Q

Disadvantage of SOAPIER: ___ & _____ (may be a repeat of responses for the client); nurses may write a narrative instead of the single problem

A

Inefficient and ineffective

25
Q

What charting is this: Review the clients status from a positive rather than a problem oriented prospective

A

Focus charting

26
Q

The advantages of focus charting is that it focuses on the signs/symptoms (objective data), it works well in ___ settings and areas where the same care and procedures are repeated frequently.

A

Acute

27
Q

The disadvantages of focused charting is it may lead to _____ labeling focus of notes and difficulty in ____ patient progress

A

Inconsistent; tracking

28
Q

What does CBE stand for?

A

Charting by exception

29
Q

Charting by exception charts only ____ findings or ____ to standards of care

A

Significant, exceptions

30
Q

Advantage or disadvantage of CBE: It reduces the amount of time spent on documentation repetitive charting on routine care, and provides an easier and understood record

A

Advantage

31
Q

T/F: The CBE disadvantage is that it omits data that may be significant, and nurses may forget how to chart.

A

True

32
Q

What does FACT documentation stand for?

A
  • Flow sheet
  • Assessment
  • Concise, integrate progress notes and flow sheets
  • Timely entries
33
Q

FACT documentation eliminates the need to chart _____

A

Normal findings

34
Q

In FACT documentation, can nurses forget the skill of charting?

A

Yes