Chapter 26 Documentation and Information Flashcards
What is DRG?
Diagnosis Related Group
What is HIPAA?
Health Insurance Portability Act
What is TJC?
The Joint Commission
anything written or printed that you rely on as record or proof is
Documentation
Joint Commission specifies guidelines for documentation
Accreditation
series of decision trees designed to cluster groups of clients together by diagnosis, surgical procedures, complications, co-morbidities, and age
Diagnosis-related group (DRG)
Explain the new rights for clients related to HIPPA
client education on privacy protections
ensuring client’s access to his or her medical records
receiving client consent before information is released
providing recourse if privacy protections are violated
The standards of documentation by the Joint Commission require
requires documentation within the context of the nursing process, as well as evidence of client and family teaching and discharge planning
It is a confidential, permanent legal documentation of information relevant to a client’s health care
Client record
oral, written, or audiotaped exchanges between caregivers
Reports
form of discussion whereby one professional caregiver gives formal advice about the level of care of a client to another caregiver
Consultations
an arrangement for services by another care provider
Referrals
means by which client needs and progress, individual therapies, client education, and discharge planning are conveyed to others in the health care team
Communication
Once of the best defenses for legal claims
Legal Documentation
To determine the accurate and timely reimbursement
Financial Billing
Learning the nature of an illness and the individual client’s responses
Education
Gathering of statistical data of clinical disorders, complications, therapies, recovery and deaths
Research
Objective, ongoing reviews to determine the degree to which quality improvement standards are met.
Auditing
What are the five guidelines for quality documentation and reporting
Factual Accurate Complete Current Organized
descriptive, objective information about what a nurse sees, hears, feels, and smells (Guideline)
factual
the use of accepted abbreviations, symbols, and system of measures that are clear and easy to understand (Guideline)
Accurate
Containing appropriate and essential information (Guideline)
Complete
Timely entries; immediate documentation of information as it is collected from the client (Guideline)
Current
Communicate information in a logical order ( Guideline)
Organized
Database, problem list, care plan, and progress notes
Problem oriented medical record (POMR)
Subjective, objective, assessment, and plan
SOAP
SOAP with intervention and evaluation added
SOAPIE
Problem, intervention, and evaluation
PIE
Involves the use of data, action, and response
Focus charting
Separate section for each discipline
Source record
Focuses on deviation from the established norm or abnormal findings, highlights trends or changes
Charting by exception
Incorporates a multidisciplinary approach to documenting care
Case Management
Multidisciplinary care plans that include client problems, key interventions, and expected outcomes.
Critical Pathways
provide baseline data to compare with changes in the clients condition
Admission nursing history forms
Data entry of assessments such as vital signs hygiene measures, ambulation, restraint checks
flow sheets
Has activity, treatment, nursing care plan sections that organize information for quick reference
Kardex
determine the hours of care and staff required for a given group of clients
Acuity records
preprinted established guidelines used to care for the client
standardized care plans
List 9 major areas to include in a change of shift report
Provide only essential background information.
Identify the client’s nursing diagnosis or health care problems and their related causes.
Describe objective measurements or observations about condition and responses tohealth problem.
Share significant information about family members.
Continuously review ongoing discharge plan.
Relay to staff any significant changes in the way therapies are to be given.
Describe instructions given in teaching plan and the responses to instructions.
Evaluate results of nursing or medical care measures.
Be clear about priorities to which oncoming staff must attend.
when the call was made, who made it, who was called, to whom information was given, what information was given, and what information was received.
Information that needs to be documented with telephone reports
Guidelines the nurse should follow when receiving a telephone order
determine the client’s name, room number, and diagnosis
repeat any prescribed orders back to the physician
use clarification questions
write TO or VO, including the date and time, name of the client, and the complete order, and sign the physician name and the nurse
follow agency policies
physician must co-sign the order within the time frame required by the institution
List 9 major information areas in a transfer report.
client’s name, age, primary physician, and medical diagnosis
summary of progress
current health status
allergies
emergency code status
family support
current nursing diagnoses or problem and care plan
any critical assessments or interventions to be completed
need for any additional equipment
A manager who is reviewing the nurses’ notes in a patient’s medical record finds the following entry, “Patient is difficult to care for, refuses suggestion for improving appetite.” Which of the following directions does the manager give to the staff nurse who entered the note?
A) Avoid rushing when charting an entry.
B) Use correction fluid to remove the entry.
C) Draw a single line through the statement and initial it.
D) Enter only objective and factual information about the patient.
D
Enter only objective and factual information about the patient.
A new graduate nurse is providing a telephone report to a patient’s health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse’s preceptor to intervene? The new nurse:
A) Uses SBAR (Situation-Background-Assessment-Recommendation) as a format when providing the report.
B) Gives a newly ordered medication before entering the order in the patient’s medical record.
C) Reads the orders back to the health care provider after receiving them and verifies their accuracy.
D) Asks the preceptor to listen in on the phone conversation.
B
Gives a newly ordered medication before entering the order in the patient’s medical record.
As you enter the patient’s room, you notice that he is anxious to say something. He quickly states, “I don’t know what’s going on; I can’t get an explanation from my doctor about my test results. I want something done about this.” Which of the following is the most appropriate documentation of the patient’s emotional status?
A) The patient has a defiant attitude and is demanding his test results.
B) The patient appears to be upset with his nurse because he wants his test results immediately.
C) The patient is demanding and complains frequently about his doctor.
D) The patient stated that he felt frustrated by the lack of information he received regarding his tests.
D
The patient stated that he felt frustrated by the lack of information he received regarding his tests.
You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, “I’ve heard a lot about these HIPAA regulations in the news lately. How will they affect my care?” Which of the following is the best response?
A) HIPAA allows all hospital staff access to your medical record.
B) HIPAA limits the information that is documented in your medical record.
C) HIPAA provides you with greater control over your personal health care information.
D) HIPAA enables health care institutions to release all of your personal information to improve continuity of care.
D
HIPAA provides you with greater control over your personal health care information.
A patient asks for a copy of her medical record. The best response by the nurse is to:
A) State that only her family may read the record.
B) Indicate that she has the right to read her record.
C) Tell her that she is not allowed to read her record.
D) Explain that only health care workers have access to her record.
B
Indicate that she has the right to read her record.
Which of the following charting entries is most accurate?
A) Patient walked up and down hallway with assistance, tolerated well.
B) Patient up, out of bed, walked down hallway and back to room, tolerated well.
C) Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk.
D) Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.
D
Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.
On the nursing unit you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system? A) Information technology. B) Electronic health record. C) Personal health information. D) Administrative information system.
B
Electronic health record.
You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply.)
A) The patient’s name, age, and admitting diagnosis
B) Allergies to food and medications
C) Your evaluation that the patient is “needy”
D) How much the patient ate for breakfast
E) That the patient’s pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol
A) The patient’s name, age, and admitting diagnosis
B) Allergies to food and medications
E) That the patient’s pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol
You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires you to intervene? The nursing student:
A) Documented medication given by another nursing student.
B) Included the date and time of all entries in the chart.
C) Stood with his back against the wall while documenting on the computer.
D) Signed all documentation electronically.
A
Documented medication given by another nursing student.
A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE?
A) “CPOE reduces transcription errors.”
B) “CPOE reduces the time necessary for health care providers to write orders.”
C) “Health care providers can write orders from any computer that has Internet access.”
D) “CPOE reduces the time nurses use to communicate with health care providers.”
D
“CPOE reduces transcription errors.”
You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet?
A) The new federal laws require that teaching sheets be e-mailed to patients after they are discharged.
B) You need to use words the patients can understand when writing the directions.
C) The form needs to be given to patients in a sealed envelope to protect their health information.
D) The names of everyone who cared for the patient in the hospital need to be included on the form in case the patient has questions at home.
B
You need to use words the patients can understand when writing the directions.
A nurse caring for a patient on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at a high risk for aspiration because the head of the bed is not elevated high enough. This warning is known as what type of system? A) Electronic health record B) Clinical documentation C) Clinical decision support system D) Computerized physician order entry
C
Clinical decision support system
While reviewing the pulmonary section of a patient’s electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse documented that the lung assessment was within normal limits. There also are no progress notes about the patient’s respiratory status in the nurse’s notes. The most likely reason for this is because:
A) The nurses forgot to document on the pulmonary system.
B) The nurses were charting by exception.
C) The computer is not working correctly.
D) The physician does not have authorization to view the nursing assessment.
B
The nurses were charting by exception.
What is an appropriate way for a nurse to dispose of printed patient information?
A) Rip several times and place in a standard trash can
B) Place in the patient’s paper-based chart
C) Place in a secure canister marked for shredding
D) Burn the documents
Place in a secure canister marked for shredding
A manager who is reviewing the nurses’ notes in a patient’s medical record finds the following entry, “Patient is difficult to care for, refuses suggestion for improving appetite.” Which of the following directions does the manager give to the staff nurse who entered the note?
A. Avoid rushing when charting an entry.
B. Use correction fluid to remove the entry.
C. Draw a single line through the statement and initial it.
D. Enter only objective and factual information about the patient.
4) Enter only objective and factual information about the patient.
A new graduate nurse is providing a telephone report to a patient’s health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse’s preceptor to intervene? The new nurse:
A. Uses SBAR (Situation-Background-Assessment-Recommendation) as a format when providing the report.
B. Gives a newly ordered medication before entering the order in the patient’s medical record.
C. Reads the orders back to the health care provider after receiving them and verifies their accuracy.
D. Asks the preceptor to listen in on the phone conversation.
2) Gives newly ordered medication before entering the order in the patient’s medical
As you enter the patient’s room, you notice that he is anxious to say something. He quickly states, “I don’t know what’s going on; I can’t get an explanation from my doctor about my test results. I want something done about this.” Which of the following is the most appropriate documentation of the patient’s emotional status?
A. The patient has a defiant attitude and is demanding his test results.
B. The patient appears to be upset with his nurse because he wants his test results immediately.
C. The patient is demanding and complains frequently about his doctor.
D. The patient stated that he felt frustrated by the lack of information he received regarding his tests.
4) The patient stated that he felt frustrated by the lack of information he received regarding his tests.
Notice the use of the word ‘appears” in selection 2 = makes it subjective to nurse’s POV
You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, “I’ve heard a lot about these HIPAA regulations in the news lately. How will they affect my care?” Which of the following is the best response?
A. HIPAA allows all hospital staff access to your medical record.
B. HIPAA limits the information that is documented in your medical record.
C. HIPAA provides you with greater control over your personal health care information.
D. HIPAA enables health care institutions to release all of your personal information to improve continuity of care.
3) HIPPA provides you with greater control over your personal health care information
patient asks for a copy of her medical record. The best response by the nurse is to:
A. State that only her family may read the record.
B. Indicate that she has the right to read her record.
C. Tell her that she is not allowed to read her record.
D. Explain that only health care workers have access to her record.
2) Indicate that she has the right to read her record.
Which of the following charting entries is most accurate?
A. Patient walked up and down hallway with assistance, tolerated well.
B. Patient up, out of bed, walked down hallway and back to room, tolerated well.
C. Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk.
D. Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.
4
Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.
On the nursing unit you are able to access a patient’s medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system? A. Information technology. B. Electronic health record. C. Personal health information. D. Administrative information system.
2) Electronic health record.
You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply.)
A.The patient’s name, age, and admitting diagnosis
B.Allergies to food and medications
C.Your evaluation that the patient is “needy”
D.How much the patient ate for breakfast
E.That the patient’s pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol
1, 2, 5.
You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires you to intervene? The nursing student:
A. Documented medication given by another nursing student.
B. Included the date and time of all entries in the chart.
C. Stood with his back against the wall while documenting on the computer.
D. Signed all documentation electronically.
.1
Documented medication given by another nursing student.
A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE?
A. “CPOE reduces transcription errors.”
B. “CPOE reduces the time necessary for health care providers to write orders.”
C. “Health care providers can write orders from any computer that has Internet access.”
D. “CPOE reduces the time nurses use to communicate with health care providers.”
A
“CPOE reduces transcription errors.”
You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet?
A. The new federal laws require that teaching sheets be e-mailed to patients after they are discharged.
B. You need to use words the patients can understand when writing the directions.
C. The form needs to be given to patients in a sealed envelope to protect their health information.
D. The names of everyone who cared for the patient in the hospital need to be included on the form in case the patient has questions at home.
2
You need to use words the patients can understand when writing the directions.
A nurse caring for a patient on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at a high risk for aspiration because the head of the bed is not elevated high enough. This warning is known as what type of system?
A. Electronic health record
B. Clinical documentation
C. Clinical decision support system
D. Computerized physician order entry
c
Clinical decision support system
What is an appropriate way for a nurse to dispose of printed patient information?
A. Rip several times and place in a standard trash can
B. Place in the patient’s paper-based chart
C. Place in a secure canister marked for shredding
D. Burn the documents
c
Place in a secure canister marked for shredding
