Documentation Flashcards
TX Administrative Code Title 22 TBON
Accurate and complete report and documentation
including
-client’s status with signs and symptoms
-nursing care rendered
-administration of meds and history
-client’s response
-contacts with other healthcare team members concerns significant events for pt
ANA Standards for Documentation
-relevant data accurately and accessible to the interprofessional team
-problems and issues shows the determination of expected outcomes and plans
-expected outcomes in measurable goal
-standardized language or recognized terms
-implementing and modifications of care plan
-coordination of care
-evaluation
-quality and performances improvement initiatives through studies and research
Signs of a pt
what you see
Symptoms of a pt
subjective to pt
Records of a pt contain
identification and demographics, consent
admission data
care plans and notes
medications and orders
labs, assessments, a summary of operations
education
discharge plans
Purpose of Records
communication
legal doc
reimbursement compliance
education research
auditing and monitoring
Fill in the Blank
The chart is a _______ _______ because it is the description of the facts at the time.
persuasive witness
Communication
multi-disciplinary
critical for continuity and risk reduction (current status and needs, progress, therapies, consultations, education, and discharge planning
Documentation needs to have ALL of these …
Accurate
Bias-free
Complete
Detailed current
Easy to read and understand
Factual
Harmless (legally)
Organized
Objective
observed data by the nurse
Descriptive
smelled, tasted
Subjective
statement from the patient
Pain is _________ with no assumptions or opinions.
subjective
Which of these documentation statements are incorrect?
-I found the patient on the floor
-Patient said they fell on the floor.
-I heard a thud and found pt on the floor
-Patient fell out of bed again!
Patient fell out of bed again
How should an entry be signed off?
time, dated with signature and title
Accurate data needs to have
exact measurements
clear
understandable
standard abbreviations only
correct spelling
time, dated with name and title
Complete data needs to include
condition changes (onset, duration, location, description, precipitating factors, and behaviors)
no blanks only N/A
Communicate with pt’s family for other info
________ reviewing the chart needs to be able to understand an accurate, clear, and comprehensive picture of the needs, interventions, and outcomes.
Anyone
You should _______ predate, pre time, prechart; data because it is _____ ________ of a record
Never; illegal falsification
Do you need complete sentences when charting data?
no
What terms should you avoid when charting
Accidentally, apparently, appears, assume, confusing, could/may be, miscalculated, mistake, somehow, unintentionally, normal, good, bad
T/F:
You should never document a pt without charting what you did about it.
true
T/F:
You should alter a pt record and it is not a crime
false, major crime
T/F: It is okay to write imprecise descriptions such as the bed was soaked, or a large amount of the urine was on the floor.
false
T/F: It is not okay to write about what someone else heard, felt, or smelled unless the information is critical.
true
What are some common formats of documentation
Narrative
Problem-Intervention-Evaluation (PIE)
SOAP/SOAPIE/SOAPIER
DAR
MAR
Kardex
Narrative documentation
written in order of pt experience happens
provides details of care, status, activities, interventions, psychosocial context, and pt’s responses
Charting by exception is also known as
shorthand notes
PIE
nursing focused onstead of medical focused and eliminates need for separate care plan
SOAP/SOAPIE/SOAPIER
Subjective
Objective
Assessment
Plan
Intervention
Evaulation
Revision
DAR
data, action, reponse
nursing admission data forms
discharge summary
flow sheets and graphic sheets
checklist, assessment, vs, I&O
MAR
Medication Admission Record
scheduled meds, unscheduled meds, allergies, and single orders
Kardex
summary of pt’s needs and care
worksheet reference of basic info not a part of the record
containing pt’s data, meds by priority, allergies, orders
Is Kardex a permanent record?
no
What color of pen should you write within nursing on paper charts?
black/ blue in print
never use white out, erasable pen, no pencil
What color of the pen should you write within nursing on paper charts?
black/ blue in print
never use white out, erasable pen, no pencil
Flow sheets
colums for data with date and times
Nurse Progress Notes
pt’s condition, problems, and complaints
interventions
responses
achieve outcomes
additional assessments
report hand offs
Should you always document when you hand off your patient and resume taking care of a pt?
yes
In nursing clinicals, it is important when documenting to?
be confidential and comply with HIPPA
no sharing info
no med record access
EAR traceable
no identifiers on paperwork
Good components of a document record needs
who
what (assessment findings, complaints, and care provided)
when (time of provided care)
where (place given meds)
how (treatment completed, response)
outcome
followups
accuracy (exact measurements)
Information needed to notify providers?
Full name and title
exact time notified
state specific lab results, symptoms, or other assessments
record response
order given
include other info
commitment for followup
symptoms
note own actions when assisting physician
If the physician does not answer,
pursue the chain of command
notify direct supervisor
record all actions
Should you use describtive language of what a pt did or label them?
descriptive language
document refusal and reason why statement
Care not documented is
care that was not provided
What are common mistakes that lead to legal actions
Fail to record health info/drugs
Fail to record nursing actions
Fail to record meds given
Fail to record response
Fail to write legibly or complete
Fail to document D/C or refusal of meds
Fail to notify healthcare teams
Fail to record late entries correctly
Fail to record referrals
Fail to record teachings
How do you correct an error on a report?
single line through with initials
On EMR -make new entry and explain error
