CNO Documentation

Question 1

Standard statements CNO documentation

Answer 1

1. Accountability
   2 Security
2. Communication

Question 2

Tools for documentation

Answer 2

• Worksheets and Kardex
• Client care plans
• Flow sheets and checklist
• Care maps and clinical pathways
• Monitoring strips

Question 3

Worksheets

Answer 3

Organize care provided

Manage time and multiple priorities

Question 4

Kardex

Answer 4

Used to communicate:
Orders
Upcoming tests
Surgeries
Special diets
Use of aids for independent living specific to individual client

Question 5

Important notes kardex

Answer 5

Entries may be erasable
As long as 
assessment
NI carried out
Client outcomes 
Must be documented in permanent health record.

Question 6

Client care plan

Answer 6

Outline of care for individual clients

Written in ink

Identify needs and wishes of clients

Question 7

Flow sheets and checklists

Answer 7

Document routine care and observations

Recorded on daily basis

Part of permanent health record

Can be used as evidence in legal proceedings

Symbols may be used

Question 8

Care maps and clinical pathways

Answer 8

Outline what care will be done

What outcomes are expected over a specified time frame

Individualized

If status client varies, variance documented including reason and action plan

Question 9

Monitoring strips

Answer 9

Provide important assessment data

Part of permanent health record

Question 10

Example of monitoring strips

Answer 10

Cardiac
Fetal or thermal monitoring
BP testing

Question 11

Incident report

Answer 11

Administrative risk management tool to track trends and patterns about group of clients overtime.

Used for quality assurance.

Must document actual care provided in clients health record.

Question 12

Documentation categories

Answer 12

Docu by inclusion

Docu by exception

Question 13

3 common docu methods

Answer 13

Focus charting

Soap/soapier charting

Narrative charting

Question 14

Focus charting

Answer 14

Identifies focus based on clients concern or behaviours determined during assessment

Uses DAR

DATA
ACTION
RESPONSE

Question 15

SOAP/SOAPIER

Answer 15

Problem oriented approach

Identifies and list client problems
Documentation
Follows accdg to identified problem

SUBJECTIVE
OBJECTIVE
ASSESSMENT 
PLAN
INTERVENTION
EVALUATION
REVISION

Question 16

Narrative charting

Answer 16

NI and impact of interventions on client outcomes are recorded in CHRONOLOGICAL ORDER covering a specific time frame

Data recorded in progress notes

Can stand alone or with other tools (flowsheets/checklist)

Question 17

Communication books and shift reports

Answer 17

Used to alert health care team to critical information.

Used to direct others to the health record where info is recorded in detail.

Relevant info communicated by these tools is documented in the health record