Chapter 15 Documenting and Reporting

Question 1

Purpose of Client Records

Answer 1

Communication Planning Client Care Auditing Health Agencies Research Education Reimbursement Legal Documentation and Health Care Analysis

Question 2

Source Oriented Record

Answer 2

Each person or department makes notations in a separate or sections of the clients chart

Question 3

Narrative Charting

Answer 3

Traditional part of the source oriented record it consists of written notes that include routine care normal findings and client problems

Question 4

Problem Oriented Medical Record

Answer 4

Database consists of all information known about the client when the client first enters the health care agency
Problem list is derived from the database it is usually kept at the front of the chart and serves as an index to the numbered entires in the progress notes
Plan of Care initial list of orders or plan of care is made with references to the active problems
Progress Notes in the POMR is a chart entry made by all health professionals involved in a clients care like ex SOAP is for subjective data objective data assessment and planning

Question 5

Ethical and Legal Consideration

Answer 5

Ensuring confidentiality of computer records are
EMRs
HIPPAA

Question 6

Types of Documentation

Answer 6

Pie model groups information into three categories like flow sheet uses specific assessment and progress notes
Focus charting intended to make the client and client concerns and strengths the focus of care
Charting by Exception document system in which only abnormal or significant findings or exceptions norms are recorded
Computerized Documentation used to manage the huge volume of info required in contemporary

Question 7

Documenting Nursing Activities

Answer 7

Admission nursing assessment comprehensive admission assessment
Nursing care plans the joint commission requires that the clinical record include evidence of client assessments
Flow sheets enables nurses to record nursing data quickly and concisely
Progress notes made by nurses provide information about the progress a client is making toward achieving
Nursing discharged referral summaries a discharge note referral summary are completed when the client is being discharged and transferred to another institution

Question 8

General guidelines for recording

Answer 8

Data and time ex 24 hour military clock
Timing frequency of documenting
Legibility all entries must be legible and easy to read
Permanence all entries on the client record are made in dark ink so the record is permanent
Accepted Terminology abbreviations are used because they are short convenient
Correct spelling
Signature
Accuracy the clients name and I’d info should be stamped and written
Completeness

Question 9

Reporting

Answer 9

The purpose of reporting is to communicate specific information to a person or group of people ex
Change of shift reports ineffective communication
Telephone reports nurses inform client primary care giver
Telephone orders care providers often order therapy
Care plan conference meeting a group of nurses to discuss solutions
Nursing rounds procedures in which two or more nurses fist selected clients at each clients bedside