Charting

Question 1

Potter and Perry documentation definition

Answer 1

Anything written or printed that is relied on as a record of proof for authorized persons.

Question 2

Nursing Practice Guidelines: Documentation

Answer 2

“Any written or computer generated information about a client that describes care or service provided to that client.”

Question 3

the medical record:

Answer 3

should be organized, clearly written, synopsis of patient’s course (admission to discharge), factual, complete and timely documentation

Question 4

nurses are legally and ethically obligated to keep client information

Answer 4

confidential

Question 5

nurses are responsible for protecting records from all

Answer 5

unauthorized readers

Question 6

HIPPAA act requires

Answer 6

disclosure or requests regarding health information

Question 7

the joint commission requires each client have an assessment:

Answer 7

physical, psychosocial, environment, self-care, client education, and discharge planning needs

Question 8

record or chart:

Answer 8

confidential permanent legal document

Question 9

reports:

Answer 9

oral, written, audiotaped exchange of information

Question 10

consultations:

Answer 10

a professional caregiver providing formal advice to another caregiver

Question 11

referrals:

Answer 11

arrangement for services by another care provider, ex. home health

Question 12

purposes of records

Answer 12

communication, legal documentation, financial billing, education, research, auditing/monitoring

Question 13

communication

Answer 13

have to have providers

Question 14

legal documentation

Answer 14

pursue or defend medical practices; if the nurse didn’t chart it then the nurse didn’t do it

Question 15

education

Answer 15

learn from charts so helps practice

Question 16

research

Answer 16

group data to see if variables increase/decrease

Question 17

auditing/monitoring

Answer 17

patient care manages and people ho do qualify assessment on chart

Question 18

guidelines for quality documentation and reporting

Answer 18

factual, accurate, complete, current, organized

Question 19

factual document (not example)

Answer 19

don’t state a patient is drunk

Question 20

example of accurate documentation

Answer 20

wound 10 cm deep, 10 cm wide, 10 cm long

Question 21

organized documentation

Answer 21

logical guideline

Question 22

how to document error in chart

Answer 22

(mark out mistake with line threw it) write error over mistake and write initials

Question 23

legal guidelines for documentation (1-11)

Answer 23

1. erasing/changing 2. critical/retaliatory remarks (always factual observations) 3. error correction 4. factual 5. blank spaces 6. legibility 7. clarification of orders 8. only chart for self 9. avoid generalized statements 10. time and sign correctly 11. keep password to myself

Question 24

how I would sign my name for charting

Answer 24

Rachael Garland TWC-FSN

Question 25

record only what you

Answer 25

see, hear, feel, smell, measure

Question 26

don’t chart

Answer 26

inferences or assumptions

Question 27

keep records

Answer 27

intact

Question 28

don’t chart symptom without also

Answer 28

charting what was done

Question 29

don’t alter

Answer 29

a client’s record… criminal offense

Question 30

when charting don’t

Answer 30

erase, apply white out, or scratch out errors

Question 31

do not document what type of remarks

Answer 31

critical or retaliatory remarks about patient or care by other health care professionals, do not enter personal opinions; (char only objective and factual observations of patient’s behavior, quote all patient comments)

Question 32

all documentation must be

Answer 32

factual

Question 33

while documenting do not leave

Answer 33

black spaces; other state can come and but in information that is false ( can go back and put in late entry)

Question 34

record all written entries

Answer 34

legibly and in black ink

Question 35

if an order is questioned, record

Answer 35

that clarification was sought

Question 36

only chart for

Answer 36

self

Question 37

when charting avoid

Answer 37

generalized statement; these are subjective

Question 38

how you would begin and end each entry

Answer 38

begin each entry with date and time and end with your signature and title