Chapter 10: documentation

Question 1

what is a healthcare documentation?

Answer 1

any written or electronically generated information about a patient

Question 2

what does the documentation do?

Answer 2

• describes the patient
• Describes the patient’s healthcare
• describes care and services provided
• includes dates of care

Question 3

standards should agree with the

Answer 3

joint commission standards

Question 4

what is a medical record…

Answer 4

The medical record is the legal documentation of care provided to a patient.

Question 5

EMR

Answer 5

EMR (electronic medical record) = a record of one episode of care

Question 6

EHR =

Answer 6

longitudinal record of health

Question 7

Nursing Documentation

Answer 7

hould be clear, concise, complete, objective, factual, nonjudgmental; should have proper spelling and grammar; should be recorded ASAP in actual order that events occurred and contain date, time, and signature

Question 8

What are the 5 aspects of documentation

Answer 8

• Nursing assessment
• Care plan
• Interventions
• Patient’s response to care
• assessment of patients ability to manage

Question 9

avoid using abbreviations that may be misunderstood. True or False

Answer 9

True

Question 10

what are the two types of documentation formats

Answer 10

• narrative

- problem-oriented medical records (POMR)

Question 11

narrative

Answer 11

he traditional method

Time-consuming and lengthy

Question 12

POMR

Answer 12

Provides a framework for documentation
Database
Problem list
Care plan
Progress notes
Charting for entire team in same section of record

Question 13

what are the 5 specific POMR documentation formats?

Answer 13

PIE
Problem, intervention, evaluation

APIE
Assessment, problem, intervention, evaluation

SOAP
Subjective, objective, assessment, plan

SOAPIE, SOAPIER
Subjective, objective, assessment, plan, intervention, evaluation, (revision)

Focus charting (DAR)
Data, action, response

Question 14

charting by exception records what type of data

Answer 14

Records only abnormal or significant data

Question 15

Right to privacy =

Answer 15

the right to be free from intrusion or disturbance in private life

Question 16

(HIPAA) stands for

Answer 16

Health Insurance Portability and Accountability Act

Question 17

The real-time process of passing patient-specific information from one caregiver to another or among interdisciplinary team members to ensure continuity of care and patient safety is often called a

Answer 17

handoff

Question 18

A sentinel event is an

Answer 18

unexpected occurrence involving death or serious physical or psychological injury or the risk of injury.

Question 19

what does SBAR stand for

Answer 19

Situation
Background
Assessment
Recommendation

Question 20

define Situation

Answer 20

What is happening at the current time?

Question 21

define Background

Answer 21

What are the circumstances leading up to this situation?

Question 22

define Assessment

Answer 22

What does the nurse think the problem is?

Question 23

define Recommendation

Answer 23

What should we do to correct the problem?

Question 24

Antic model

Answer 24

Administrative data (Name, record number, location)

New clinical information to be updated
(Real-time information )

Tasks to be performed (Must be clearly explained)

Illness severity
(Must be communicated)

Contingency
(Plans for change in clinical status)

Question 25

Incident Reports

Answer 25

When an unusual and unexpected event involving a patient, visitor, or staff member occurs, an incident report is completed.