Ch. 18: Documenting and Reporting-MJ Flashcards
The act of recording patient status and care in written or electronic form or in combination of the two forms
Documenting
What other terms are considered documenting?
Documenting, reporting, charting
What should be included in the documentation?
Health history Exams Tests Treatment Outcomes
What is the purpose of documentation?
To provide continuity of care among all team members who provide care to the same patient
Documentation should always reflect the _____
Nursing process
Documentation provides communication between ____-
Providers
Documentation does ____ of care
Continuity
Documentation is an ____ tool and can be used during ____
Education tool; research
Documentation give a _____ of care
Legal document
T/F: Documentation provides quality improvement and reimbursement.
True
What are the 4 advantages of written documentation?
- Familiar
- Does not require a large database networks and is secure to function
- Not dependent on power/electricity
- Inexpensive
What are the disadvantages to written documentation?
- Access may be delayed
- Retrieving info may be slow
- Time consuming
- High risk patient error
- Storage is expensive
- Difficult to protect confidentiality
What are the advantages to electronic documentation?
- Communication is improved among health providers
- Improved access to info
- Saves time
- Improves the quality of care
What are the disadvantages to electronic documentation?
- Expensive
- Electrical issues
- Difficulties with learning
- Lack of integration
What are some examples of common types of charting?
Narrative, PIE, SOAPIER, Focus, Charting by Exception, FACT system, and electronic entry format
Which charting type tells the story of the patient?
Narrative
What is the advantage to narrative charting?
Helps set a goal for the patient and tracks the clients health status
What are the disadvantages to narrative charting?
Time consuming, disorganized, contain multiple entries, must read the entire note of the client, and does not readily identify problems and trends
What does PIE stand for?
Problem intervention evaluation
What are the advantages to PIE charting?
Eliminates the need for a separate care plan and provides a nursing focus rather than a medical focus record
What is the disadvantage to PIE?
Does not document the planning portion of the nursing process
What does SOAP(IER) stand for?
Subjective data Objective data Assessment Plan Intervention Evaluation Revision
Advantages of SOAPIER: To shift the focus from the patient to the ___, promoting a medical model instead of the _____
Disease, nursing process
Disadvantage of SOAPIER: ___ & _____ (may be a repeat of responses for the client); nurses may write a narrative instead of the single problem
Inefficient and ineffective
What charting is this: Review the clients status from a positive rather than a problem oriented prospective
Focus charting
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.
Acute
The disadvantages of focused charting is it may lead to _____ labeling focus of notes and difficulty in ____ patient progress
Inconsistent; tracking
What does CBE stand for?
Charting by exception
Charting by exception charts only ____ findings or ____ to standards of care
Significant, exceptions
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
Advantage
T/F: The CBE disadvantage is that it omits data that may be significant, and nurses may forget how to chart.
True
What does FACT documentation stand for?
- Flow sheet
- Assessment
- Concise, integrate progress notes and flow sheets
- Timely entries
FACT documentation eliminates the need to chart _____
Normal findings
In FACT documentation, can nurses forget the skill of charting?
Yes
