Documentation

Question 1

What are 3 nursing related functions of the patient Health Care Record?

Answer 1

1. communication
2. assessment
3. care planning

Question 2

What are other functions of the patient health record?

Answer 2

-legal document, quality assurance, reimbursement, research, education

Question 3

When will insurance not reimburse for patient care?

Answer 3

Any time harm is done to patient by hospital/facility staff/procedure/event

Question 4

What is unique about CHF and reimbursement?

Answer 4

If return to hospital 30 days after d/c with CHF insurance won’t reimburse

Question 5

3 potential issues with Electronic Health Record?

Answer 5

HIPAA (secure login)
Implementation is expensive
Training new users takes effort

Question 6

Important elements of good documentation (5)

Answer 6

-confidential, accurate, concise/complete/ objective, organized and timely

Question 7

6 types of documentation records

Answer 7

Clinical Pathway
Admission
Nursing Discharge summary
Nursing Progress Note
Plan of Care
Flow Sheet

Question 8

What does a Flow Sheet have on it?

Answer 8

Vital signs, assessment, lab data

Question 9

What does a Plan of Care have on it?

Answer 9

care plan and concept map

Question 10

What is a clinical pathway documentation?

Answer 10

targeted to medical procedure/predictable condition

Question 11

What is on a nursing discharge summary?

Answer 11

expectations after d/c, follow up appointment, when to reach out for assistance

Question 12

What are 4 types of Nursing Progress Note?

Answer 12

1. narrative
2. SOAP
3. PIE
4. FOCUS

Question 13

This kind of note is easiest to learn, allows detailed explanations and is time sequences phrases but it can be difficult to review for details and takes the longest time

Answer 13

Narrative

Question 14

This kind of note is a progress note for only 1 health problem and isnt used for general charting

Answer 14

SOAP

Question 15

What does SOAP stand for?

Answer 15

Subjective (what patient expresses), Objective (vital signs, labs), Assessment (conclusion based on S and O), Plan (interventions)

Question 16

What does PIE stand for?

Answer 16

Problem, Intervention, Evaluation

Question 17

What kind of note incorporates plan of care into progress note using nursing diagnosis and is not interdisiplinary?

Answer 17

PIE

Question 18

What kind of note is broadest and focuses on problem area. It is often used for patient education but it not multidisciplinary

Answer 18

FOCUS (DAR)

Question 19

What does DAR stand for

Answer 19

Data, Action, Response

Question 20

When can you use Charting by exception?

Answer 20

only for head to toe assessment

Question 21

What do you do ibn charting by exception?

Answer 21

Chart only what is abnormal

Question 22

Who can use Charting by exception?

Answer 22

someone proficient in assessment- not a novice

Question 23

What documentation occurs when there is an error? Where is it located?

Answer 23

incident report , internal- NOT part of patient chart

Question 24

What does SBAR stand for?

Answer 24

Situation, Background, Assessment, Recommendation

Question 25

What do you discuss during Situation in SBAR?

Answer 25

• clear brief statement o what is happening in present time

- provide your name, patient name, unit, room number, vitals

Question 26

What do you discuss during Background in SBAR?

Answer 26

-releveant clinical information related to situation
what are circumstances leading up situation?
-diagnosis, allergies, baseline vitals/assessment, code status, meds, iv, labs, test results

Question 27

What do you discuss during Assessment in SBAR?

Answer 27

• your assessment of patient
• what do you think the problem is?
• focused subjective and objective assessment

Question 28

What do you discuss during Recommendation in SBAR?

Answer 28

• actions requested to help situation
• What to do to correct the problem?
• order change/referral, visit by provider

Question 29

3 types of orders a nurse can receive?

Answer 29

Verbal (emergencies)
Telephone
Written (preferred)

Question 30

What is most important thing to give during handoff?

Answer 30

Code status

Question 31

Where do yuo give report to next shift?

Answer 31

Bedside