Ch 26: Documentation

Question 1

What does HIPPA stand for?

Answer 1

Health Insurance Portability and Accountability Act

Question 2

Who specifies the guidlines for documentation?

Answer 2

The Joint Commission

Question 3

How may handoff reports be given?

Answer 3

• Face to face
• In writing
• Telephone
• Audio recording

Question 4

When are hand-off reports given?

Answer 4

• Change of shift
• Transfer of patient

Question 5

Who gets the change of shift report and what does it include?

Answer 5

• All nurses on next shift
• Includes
  
  • Condition
  • Required care
  • Treatments
  • Medications
  • Any recent or anticipated changes

Question 6

When is a Transfer Report given?

Answer 6

• Given whenever the patient is transferred to other health care unit such as:
  
  • Nursing unit to nursing unit transfer
  • Nursing unit to diagnostic area
  • Special settings (OR, ED)
  • Discharge and interfacility transfer

Question 7

The nurse receiving a telephone report should document

Answer 7

• the date and time,
• the name of the person giving the information,
• subject of the information received
• Sign the notation.

Question 8

Telephone reports usually include

Answer 8

• the client’s name
• medical diagnosis
• changes in nursing assessment
• vital signs
• significant lab data
• related nursing interventions

Question 9

Define an Incident (Occurrence) Report

Answer 9

A report that documents any event that is not consistent with the routine operation of a health care unit or routine care of a patient

Question 10

What are some examples of things that would require an Incident Report?

Answer 10

• Patient falls
• Needlestick injuries
• A visitor having symptoms of illness.
• Medication administration errors
• Accidental omission of ordered therapies and
• Circumstances that lead to injury or a risk for patient injury

Question 11

What should be included in an Incident Report?

Answer 11

• an objective description of what happened,
• what you observed
• the follow up actions taken

Question 12

Does the Nurse need to notify the HCP when an insident happens?

Answer 12

Yep

Question 13

Are incident reports included in the pt record?

Answer 13

Nope

They are for internal QC

Question 14

What is the difference between a TO and a VO?

Answer 14

• TO is a Telephone Order
• VO is a verbal In Person order
• Both are oral reports

Question 15

What is the documentation responsibility of an HCP regarding TOs and VOs?

Answer 15

Sign the chart with time set by hospital policy

Question 16

What is SOAP Charting?

Answer 16

• A charting format that includes the following data:
  
  • Subjective
  • Objective
  • Assessment
  • Plan

Question 17

What is PIE charting?

Answer 17

• A charting format that includes the following data:
  
  • Problem
  • Intervention
  • Evaluation

Question 18

What is SOAPIE Charting?

Answer 18

A combination of Soap and Pie charting

Question 19

What format is used for Focus charting?

Answer 19

DAR

• Data
• Action
• Response

Question 20

What is CBE charting?

Answer 20

• Charting by Exception
• Only chart when something goes wrong
• Bad and shouldn’t be used as it assumes that all else is as it should be if it wasn’t reported on.

Question 21

What should we keep in mind regarding IV’s at discharge?

Answer 21

Make sure that fucker is out!

Question 22

What is the summary of discharge that should be communicated to the pt?

Answer 22

• Use clear, concise description in pt’s language
• Provide care instruction w/ printed documentation and teachback
• ID precautions of self-care and meds
• Review signs/symptoms/complications that need to be reported to HCP
• Give contact info for relevant HCPs and community resources
• Review follow up and continuous treatment
• List time of discharge, mode of xportation and who accompanied client

Question 23

What does SBAR stand for?

Answer 23

• Situation
• Background
• Assessment
• Recommendation

Question 24

What does the “I” in ISBAR stand for?

Answer 24

Introduction/Identify self