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NS371—Fundamentals of Nursing > Documentation > Flashcards

Documentation Flashcards

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1
Q

maintaining pt confidentiality on computers (6)

A
  • Do not share personal password
  • Never leave the computer unattended after logging in
  • Do not leave pt info on screen where others can see
  • Shred all unnecessary sheets - cut pt’s ID info off paper if you must take it out of facility
  • IT must install firewall
  • Follow policy for charting sensitive info
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2
Q

purposes of pt records (8)

A
  • Communication - prevents repetition & delay in care
  • Planning care - evaluate plan’s effectiveness
  • Auditing health agencies - can be reviewed for quality assurance
  • Research - info about populations of pts can help with treatment plans for others
  • Education
  • Reimbursement - must contain correct DRG (diagnosis related groups)
  • Legal documenation - admission in court as evidence unless pt objects
  • Health care analysis - ID agency needs - overutilized & underutilized resources
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3
Q

most common type of charting

A

source oriented records

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4
Q

easily located each discipline’s form

easy to trace info specific to one’s discipline

info about particular problems distributed throughout

A

source oriented charting

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5
Q

must chart in clear, chronologic, coherent manner

A

narrative charting

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6
Q

Data arranged according to pt’s problem

encourages collaboration

alerts caregivers to pt needs

caregivers differ in ability to use

takes constant vigilance to maintain updated list

inefficient because assessments/interventions must be repeated

A

problem oriented medical record

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7
Q

parts of the problem-oriented chart (4)

A

database

problem list

plan of care

progress notes

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8
Q

SOAPIER documentation

A
  • S - subjective
  • O - objective
  • A - assessment
  • P - plans
  • I - interventions
  • E - evaluations
  • R - revisions
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9
Q

focuses on pt’s strengths

A

focus charting

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10
Q

DAR

A

data, action, response

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11
Q

CBE

A

charting by exception

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12
Q

only charting what is different/problematic/unexpected

eliminates lengthy, repetitive notes

makes pt changes more obvious

risk for negligence

A

charting by exception

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13
Q

advantages of computer documentation (5)

A
  • Focus on pt outcomes
  • Links sources to pt info
  • Bedside terminals eliminate paper notes
  • Legibility improved
  • Improves communication
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14
Q

disadvantages of computer documentation (4)

A
  • Privacy may be infringed
  • Tech breakdowns
  • Expensive
  • Extended training required
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15
Q

Assign a case manager to pt

ensures quality, cost-effective care delivered w/i length of stay

A

case management model

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16
Q

critical pathways used for…

A

common diseases

17
Q

variance

document…

A

a goal that was not met

  • Document actions taken to correct
  • Document justification of actions taken
18
Q

Concise method of organizing & recording data

Cards kept in portable index file or computer

Info quickly accessible

Pertinent info about pt arranged in sections

A

kardexes

19
Q

sections in a kardex (6)

A
  • Allergies
  • List of meds
  • Daily treatment & procedures
  • Diagnostic procedures
  • Physical needs to be met
  • Stated goals
20
Q

examples of flow sheets

A
  • Graphic record - VS, weight, etc
  • I & O record
  • MAR - medication administration record
  • Skin assessment record
21
Q

Completed when pt discharged or transferred

A

discharge/referral summary

22
Q

components of a d/c and referral summary (8)

A
  • Description of pt physical, emotional, mental status
  • Resolved health problems
  • Tx to be continued
  • Current meds
  • Restrictions
  • Self-care abilities
  • Support networks
  • Referral services
23
Q

administers medicare

A

Health Care Financing Administration

24
Q

regulates documentation for long term care

A

Omnibus Budget Reconciliation Act (OBRA)

25
Q

long term care documentation

  • Minimum Data Set assessment & screening w/i ______ of admission
  • Plan of care w/i _____ of admission
  • Review & revise plan of care every ______
  • Report any change in pt condition to Dr & family w/i _____ & measures taken to change condition
A

4 days

7 days

3 months

24 hours

26
Q

there must be an RN in a long term care facility at least ___ hrs per day

A

8

27
Q

_______ requires standardized documentation for home health care

A

Health Care Financing Administration

28
Q

2 record required for home health care

A
  • Home health certifications & plan of treatment form
  • Medical update & pt info form
29
Q

how to sign documentation

A

“S. Boyer, SN”

30
Q

documentation NOs (6)

A
  • chart in advance
  • Leave blank space - strike through empty space & sign
  • Use vague terms
  • Alter record
  • Record assumptions
  • Include “pt” or pt’s name or include “I did…” (conciseness)
31
Q
  • Ask & respond to questions
  • Provide basic IDing info
  • ISBAR
A

change of shift report

32
Q

used to report to other caregivers about a pt’s situation

A

ISBAR

33
Q

rules about telephone/verbal orders (5)

A
  • Write complete order down
    • “T-O” - telephone order; “V-O” - verbal order
    • “Dr. XYZ/S. Boyer”
  • Read it back to ensure accuracy
  • Question any order unusual or contraindicated
  • Have PCP verbally validate read-back
  • Countersign by PCP in 24hr
34
Q
  • Meeting to discuss potential solutions to pt problems
  • Allows each nurse opportunity to offer opinion
  • Other providers invited to offer expertise
A

plan of care conference

35
Q
  • 2+ nurses visit pts at bedside, often with case manager
  • Obtain info that will help plan nursing care
  • Provide pt opportunity to discuss care
  • Use simple terms for pt’s understanding
A

nursing rounds

36
Q

Joint Commision requires care plans to include… (5)

A
  1. Evidence of client assessment
  2. Nursing diagnosis
  3. Nursing interventions
  4. Client outcome
  5. Current nursing care plan
37
Q

RAI and MDS use

A

screening tool to establish a baseline of new incoming clients into a long-term care facility and additional periodic documentation reviewing and revising the assessment as clients’ needs change

38
Q

elements of malpractice

A

(1) a professional duty owed to the patient; (2) breach of such duty; (3) injury caused by the breach; and (4) resulting damages

NS371—Fundamentals of Nursing (12 decks)

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