Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

NURS 305 > Chapter 26: Documentation and Informatics > Flashcards

Chapter 26: Documentation and Informatics Flashcards

1
Q

Documentation

A

anything written or printed which is relied on as proof of all patient care activities

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Documentation must be

A 
Accurate
Comprehensive and flexible
Maintain continuity of care
Track patient outcomes
Reflect current standards of nursing practice
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

When a plan is not communicated to all members of the health care team

A

care becomes fragmented, tasks are repeated, and often delays or omissions in therapy occur.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

When documenting, nurses must keep in mind:

A
  • Quality of care
  • The standards of regulatory agencies and nursing practice
  • The reimbursement structure in the health care system
  • The legal guidelines
  • Principles to maintain confidentiality of information
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Institutional standards or policies often

A

dictate the frequency of documentation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is generally the first reference used when it is suspected that standards were not met?

A

nurses notes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Institutional accreditation

A

Standards set by The Joint Commission (TJC) and/or Center for Medicare and Medicaid services (CMS) must be met to receive accreditation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Reports may be

A

oral, written or audiotaped (not as common a way of shift change report)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Common types of reports given by nurses

A

Change of Shift Reports
Telephone Reports
Hand-off Reports
Incident Reports

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Nurses also engage in

A

consultations and referrals

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Purposes of Medical Records include

A 
Communication
Legal Documentation
Reimbursement
Education
Research
Auditing/Monitoring
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Purposes of Record: Communication

A

Document information as you provide care.

Do not “save all of your charting for later” to do at one time… you will forget and omit important details.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Communication includes

A 
Patient Needs and Progress
Individual Therapies
Content of Consultations
Patient Education
Discharge Planning
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Purposes of Records: Legal Documentation (Table 26-1, p. 351)

A

The best defense for legal claims.

If you don’t document it, you didn’t do it.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Care must be

A

goal oriented, individualized and based on the nursing assessment.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Common Charting Mistakes

A
  1. Failing to record pertinent health or drug information
  2. Failing to record nursing actions
  3. Failing to record that medications have been given
  4. Failing to record drug reactions
  5. Failing to record changes in patient’s condition
  6. Writing illegible or incomplete records
  7. Failing to document discontinued medications
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Purposes of Records: Reimbursement

A

DRG’s are the basis for establishing reimbursement: Classification based on diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Hospitals are reimbursed based off

A

DRG (Diagnosis Related Groups)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Purposes of Records: Education

A

Reading the patient care record helps to learn the nature of an illness and the patient’s response:
Identify patterns of information from patient to patient.
Learn to anticipate the care required for a patient.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Purposes of Records: Research

A

Charts are reviewed by nurse researchers for example, to gather statistical data, review complications, review therapies.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Purposes of Records: Auditing/Monitoring

A 
Accrediting agencies (TJC) require quality improvement programs:
Data must be shared
A plan must be in place for remediation/correction of deficiencies
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Auditing/Monitoring includes

A 
Patient teaching
Discharge planning
Performance of individualized care
Proof standards of care have been 
   met
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Goal for 2014 that all medical records will be kept electronically which will enhance

A
  • communication among health care providers
  • patient safety by providing clear, legible, standardized documentation and including physician order entry
  • accessibility to health care records for continuity of care
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Confidentiality

A

It is an ethical obligation to keep and maintain confidentiality concerning patient information.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Who can have legitimate access to the patient’s records?

A

only staff directly involved in the patient’s care

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What organization governs all areas of patient information and management of that information?

A

HIPAA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

As student nurses, you insure confidentiality by

A

not including any patient identifiers in your clinical care plans

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

EHR has inherent risks:

A

anyone with access to an agency computer station can access any patient information.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Security mechanisms in place include

A

Auto shut off
Firewalls
Antivirus/spyware-detection

30
Q

Handling of Patient Information

A
  • Should not be left out for view by unauthorized people
  • Do not remove printed patient info from the agency
  • On fax machines, use programmed speed dial
  • Place computer/fax machines in protected areas
31
Q

Disposing of Patient Information

A

Destroy (shred) any printed information containing PHI.

Know and follow disposal policies at the institution where you work.

32
Q

Standards: Record Keeping Forms

A

Usually derived from institutional standards of practice or guidelines established from accrediting agencies.

33
Q

Record Keeping Forms include

A
  1. Admission History
  2. Flow Sheets and Graphic Records
  3. Patient Care Summary or Kardex
  4. Standardized Care Plans
  5. Discharge Summary Forms
  6. Acuity records
34
Q

Guidelines for Quality Documentation and Reporting have five important characteristics: (T. 26-1 p. 358)

A
  1. Factual
  2. Accurate
  3. Complete
  4. Current
  5. Organized
35
Q

Factual

A

descriptive, objective information about what the nurse sees, hears, feels, and smells.

36
Q

Guidelines for Quality Documentation and Reporting: Factual

A

Avoid vague terms such as “apparently”, “seems” as they suggest opinion.

Record subjective data from the patient with quotation marks.

37
Q

Guidelines for Quality Documentation and Reporting: Accuracy

A
  • Use approved abbreviations only.
  • Use correct spelling and grammar.
  • Use units of measurement such as cm, inches, ml, etc.
  • Sign and date all entries
  • Avoid the use of unnecessary words and irrelevant detail.
38
Q

Guidelines for Quality Documentation and Reporting: Complete

A

The entries in the medical record document the care you gave your patient and the patient response to treatment.

39
Q

Guidelines for Quality Documentation and Reporting: Current

A

Make entries timely: Document activities or finding at the time of the occurrence.

40
Q

What activities should you document at the time of occurrence?

A
  • Vital signs
  • Pain assessment
  • Administration of medications and treatments/Patient response to the treatment
  • Preparation for diagnostics/surgery
  • Change in patient condition, who was notified
  • Admission, transfer, discharge
41
Q

Guidelines for Quality Documentation and Reporting: Organized

A

Make your notes concise, clear, and to the point.

Apply critical thinking and the nursing process to give logic and organization to your documentation.

42
Q

Narrative Notes (B. 26-1 p. 363) include

A

SOAP
PIE
DAR

*Becoming obsolete with advent of the EHR

43
Q

SOAP

A

Subjective
Objective
Assessment
Plan

44
Q

PIE

A

Problem
Intervention
Evaluation

45
Q

DAR

A

Data
Action
Response

46
Q

Problem-Oriented Medical Record

A

A system of organizing documentation to place the primary focus on patients’ individual problems.

47
Q

Problem-Oriented Medical Record includes

A

Data Base
Problem List
Care Plan
Progress Notes

48
Q

Data Base

A

contains all available assessment data

49
Q

Problem List

A

Identified problems including physiological, psychological, social, cultural, spiritual, developmental, and environmental needs

50
Q

Care Plan

A

care plan for each problem

51
Q

Progress notes

A

from all health care team members

52
Q

Data is considered normal unless

A

otherwise noted

53
Q

Charting by Exception

A
  1. Charting according to deviations from what is considered normal.
  2. There is an assumption that all standards are met unless otherwise noted.
54
Q

Case Management: Interprofessional approach. Manages patient care for:

A

Cost effectiveness
Evaluation of care plan goals/outcomes
Mutual needs of patient and family
Timely discharge planning

55
Q

Critical Pathways

A

display goals for patients and provide the corresponding ideal sequence and timing of staff actions for achieving those goals with optimal efficiency. B. 26-2 p. 365

56
Q

Common Record Keeping Forms

A

Admission Nursing History

Flow sheets/graphic records

Patient care summary

Standardized care plans (individualized)

Discharge summary forms B. 26-3 p. 366

57
Q

Patient Care Summary

A

Document automatically updates to include, for example:
Basic demographic data
Diagnosis/history/orders/family contact info, code status, allergies

58
Q

Acuity Rating System

A

How much nursing care is involved in a particular patient based on diagnosis, patient condition, needed interventions, and patient participation in their care (full care vs. ambulatory) over a 24/hr period

59
Q

Staffing is many times based on

A

acuity

60
Q

Nurse to Patient Ratios

A

How many patients can 1 nurse safely care for in a 24 hour period? (dynamic process)

61
Q

Purpose of reporting

A

Standardized communication helps ensure patient safety.

62
Q

A nurse should avoid using

A

Derogatory or inappropriate comments about a patient or family member.
May lead to legal charges.

63
Q

Hand-Off Report

A

SBAR (Situation, Background, Assessment, Recommendation)

64
Q

Telephone Report

A

Read back report

65
Q

Telephone and Verbal Orders

A

RBO (B, 26-4 p. 367)

*Limit verbal orders to emergency situations.

66
Q

Incident/Occurrence Report:

A 
Any event not consistent with standards of care or routine care of the patient. For example:
falls, 
injuries, 
near-misses, 
issues with family members 
medication issues.
67
Q

Incident reports are important for

A

of all Quality Improvement and Risk management programs.

68
Q

Health Informatics

A

Management and processing of information, mainly by computer, to facilitate:
Acquisition, processing and interpretation of health-related data, and communication.

69
Q

Goal of Health Informatics

A

to enhance the quality and efficiency of care

70
Q

Nurses are tasked in acquiring

A

awareness and competence in informatics and use of IT in BSN, MSN and doctoral nursing programs.

71
Q

Nursing Informatics

A

a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice (ANA, 2008).

NURS 305 (30 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions