Documentation Flashcards
Healthcare workers spend ____% of time documenting
40 %
Reduces errors, built in clinical alerts are all factors of __?
Electronic health records
When a nurse documents clients finding using flow sheet and only document unusual findings. For “normal” findings they document “WDL”.
This is an example of ?
Charting by exception
Progress notes are useful for ?
Clarification and follow up on unusual findings
Provider, PT, OT, RT, progress notes are important to read in order to ?
Help with collaboration, apprise to patients plan of care
______ allows providers to document findings in an organized manner.
SOAP
S in SOAP stands for?
Subjective
O in SOAP stands for ?
Objective
A in SOAP stands for?
Assessment
P in SOAP stands for ?
Plan
What elements of the nursing process are missing in SOAP?
Intervention and evaluation
Another way to document findings in an organized manner is through ____
PIE
The P in PIE stands for ?
Problem
The I in PIE stands for ?
Intervention
The E in PIE stand for ?
Evaluation
When computers go down and you must use paper charting this is called?
Downtime charting
The guidelines for sound documentation are based on what acronym?
FACT
F in FACT stands for?
Factual
Concrete objective findings
Subjective findings in “quotations”
A in FACT stands for ?
Accurate
Use exact measurements
C in FACT stands for?
Complete
Do not leave out important information
T in FACT stands for?
Timely
Document after providing care
When are verbal orders used?
Only in emergency situations
When getting a telephone order you must confirm?
Patients ID, allergies & have patients chart available
In telephone orders each medication ordered must contain which information?
Name, dose, strength, route, time/frequency, indication, special instructions
True or False
Record prescription in patient’s chart while taking order
True
