Documentation Flashcards
documentation or reporting: proves care was provided
documentation
documentation or reporting: verbal sharing of info about patients with another person or persons
reporting
documentation or reporting: includes all assessments
documentation
documentation or reporting: uses SBAR
reporting
nursing functions of patient health record (3)
communication, assessment, care planning
non-nursing functions of patient health record (5)
legal document, quality assurance, reimbursement, research, education
conditions that aren’t reimbursed
nosocomial infections, foreign object retained after surgery, severe pressure ulcers, falls, central line or urinary catheter infections (“never events”)
computerized way to compile patient data
electronic health record (EHR)
major functions of EHR software
computerized physician order entry, electronic med admin, clinical decision support
documentation elements (5)
confidentiality, accurate, concise/complete, objective, organized and timely
don’t batch chart!
types of documentation records (6)
admission entry/assessment flow sheet: vitals, assessment, lab data plan of care: care plan, concept map clinical pathway nursing discharge summary nursing progress notes
types of nursing progress notes (4)
Narrative, SOAP, PIE, FOCUS
SOAP
subjective - patient expresses
objective - vital signs, lab data
assessment - a “conclusion”
plan - nursing interventions used to address conclusion
disadvantage: problem focused
PIE
Problem: nursing diagnosis
Intervention
Evaluation
disadvantage: not interdisciplinary
Focus (DAR)
Focus in one column, then:
Data
Action
Response
disadvantage: not interdisciplinary
Charting by exception
document only what is abnormal (for assessment, relative to population)
disadvantage: you have to know normal assessment before using this
t/f: Incident report is part of a patient’s chart
false. The incident itself is charted, but the fact that an incident report was filed is not.
SBAR
(Introduction) Situation Background Assessment Recommendation (Repeat back)
Which part of SBAR?
I am Nurse Smith caring for Mrs. Evergreen today in room 346 on the foundations unit. Mrs. Evergreen presented with a blood pressure of 84/49, pallor, dizziness
Situation
Which part of SBAR: lab results
Background
Which part of SBAR: code status
Background
Which part of SBAR: your impression
Assessment
Which part of SBAR: suggesting an order change
Recommendation
Can an order be given verbally outside an emergency situation?
No – the provider should put it in writing
What has to be included in every handoff?
Code status
