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Exam 3 > Documentation > Flashcards

Documentation Flashcards

1
Q

What is the Texas Administrative Code Title 22 Tx BON?

A

The standards that are applicable to ALL NURSES

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2
Q

Board of Nursing Tx expects all nurses to report and document which of the following? Select all that apply

  • signs and symptoms
  • what you did in the room
  • meds and treatments (what you did for them)
  • the pts response
  • contacts with other health care workers
  • relavent data
A

signs and symptoms
what you did in the room
meds and treatments (what you did for them)
the pts response
contacts with other healthcare workers

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3
Q

What does ANA stand for?

A

american nurses association

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4
Q

what are the ANA standards for documentation?

  • relevant data
  • problems and issues
  • expected outcomes
  • signs and symptoms
  • standardized language, normal terminology
  • implementation and any modifications
  • coordination of care
  • results of evaluation
  • quality and performance improvement initiatives
A

relevant data
problems and issues
expected outcomes (as measurable goals; where you want the pt to be after the treatment)
standardized language
implementation and any modifications
coordination of care
results of evaluation
quality and performance improvement initiatives

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5
Q

What should the records contain?

  • pt identification and demographic data
  • informed consent for trtmnt and procedure
  • admission data
  • nursing problems
  • care plans
  • record of nursing care treatment and evaluation
  • medical history
  • medical diagnosis (dr’s)
  • therapeutic orders
  • progress notes
  • physical assessment findings
  • diagnostic study findings
  • pt education
  • summary of operations
  • discharge plan and summary
  • communication
A

pt id and demographic data
informed consent for trtmnt and procedure
admission data
nursing problems
care plans
record of nursing care trtmnt and eval
medical history
medical diagnosis
therapeutic orders
progress notes
physical assessment findings
diagnostic study findings
pt education
summary of operations
discharge plan and summary

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6
Q

when does discharge planning start?

A

discharge planning starts on admission

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7
Q

what is the purpose of records?

A

so that the nurse doesn’t get sued

if it isnt recorded, it never happened

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8
Q

which of these includes the purpose of records

  • communication
  • admission data
  • legal document
  • reimbursement compliance
  • education
  • research
  • auditing and monitering
  • continuity of care
A

communication
legal document
reimbursement compliance
education
research
auditing and monitering
continuity of care

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9
Q

What is communication in terms of nursing?

A

Multi disciplinary

Critical for continuity and risk reduction

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10
Q

Which of these help with nursing communication?

  • current pt status/ needs
  • pt progress
  • pt therapies
  • pt consultations
  • pt education
  • pt discharge planning
  • how much they slept last night
A

current pt status
pt progress
pt therapies
pt consultations
pt education
pt discharge planning

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11
Q

What should documentation be?

  • factual
  • accurate
  • complete
  • current
  • organized
  • all of the above
A

ALL OF THE ABOVE

What did you feel?
What did you see?

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12
Q

What should the nurse NEVER do?

A

NEVER PUT AN ASSUMPTION OR OPINION IN THE CHART!!!

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13
Q

A factual document should be?

A

objective
descriptive
subjective (quotes)

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14
Q

An accurate documentation should be/have?

A

exact measurements
clear
understandable
standard abbreviations only
timed, dated with signature and title
CORRECT SPELLING

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15
Q

A complete document should have?

A

Condition change ( onset, duration,, location, description, precipitating factors, behaviors… )
DO NOT LEAVE BLANKS, USE N/A
Communication with patient and family

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16
Q

What is the whole picture for documenting/ charting?

A

anyone reviewing the chart must be able to understand an accurate, clear, and comprehensive picture of:

  • pts needs ( what did you see )
  • nurses interventions ( what did you do )
  • pts outcome ( what was the outcome )
17
Q

When should documentation start?

A

ASAP
time of occurance
use military time
NEVER PRE-TIME, PRE-DATE, PRE-CHART BC ITS ILLEGAL

18
Q

Should the chart be organized

  • chronological order
  • clear
  • concise
  • to the point
  • complete sentences not needed

Yes/ No

A

Yes

nurse dont need to type everything in detail, just needs to know what happened

19
Q

Should the nurse avoid terms that’ll make them look incompetent?

A

Yes
Also the terms are assumption terms

20
Q

What are examples of avoided terms?

A
  • accidentally
  • apparently
  • APPEARS
  • could be
  • miscalculated
  • somehow
  • unintentionally
  • NORMAL
  • GOOD
  • BAD
21
Q

Which of these are some documentation don’ts?

  • don’t document a pts problem without charting what you did about it
  • dont alter, no white out or use an eraser
  • dont use quotations
  • dont chart ahead of time, its fraud
  • dont chart what someone else heard, felt, or smelled, unless info is critical
  • dont write imprecise descriptions; ie bed soaked, large amount
A

dont document pts problem without charting what you did about it
dont alter, no white out or use an eraser
dont chart ahead of time its fraud
dont chart what someone else heard, felt, or smelled, unless info is critical
dont write imprecise descriptions; ie, bed soaked, large amount,

22
Q

What are some common formats of charting?

  • Narrative
  • Problem- Intervention - Evaluation (PIE)
  • SOAP/ SOAPIE/ SOAPIER
  • DAR
  • Dhar Man
A

Narrative
Problem - Intervention - Evaluation (PIE)
SOAP/ SOAPIE/ SOAPIER
DAR

23
Q

What does the nurse put down in a narrative format?

A

written in order of pt experience

provides details of pts care, status, activities, nursing interventions, psychological context and response to trtmnt

24
Q

What does PIE stand for?

A

Problem - Intervention - Evaluation

nursing focused instead of medical focused and eliminates need for separate care plan

25
Q

What does SOAP/ SOAPIE/ SOAPIER stand for?

A

Subjective data
Objective data
Assessment
Plan
Intervention
Evaluation
Revision

26
Q

What does DAR stand for?

A

data
action
response

27
Q

What are some different forms for charting?

  • admission data forms
  • discharge summary
  • flow sheets and graphic sheets
  • MER
  • Kardex
  • paper charts
A

admission data forms

discharge summary

flow sheets and graphic sheets ( check list, vital signs, intake and output)

MER ( Medication Administration Records )

Kardex (not permanent record, summary of pt needs and care)

28
Q

What does the nurse put in the MER?

A

scheduled meds, unscheduled meds, drug allergies, single order medications

29
Q

Paper charts should always be written in

  • Blue pen
  • Black pen
  • Pencil
  • Both blue and black pen, whichever one
A

both blue and black pen, whichever one

should be print or cursive, no erasable ink, NEVER ERASE

30
Q

What is Kardex?

A

a summary worksheet reference of basic info thats not traditionally part of the record
- family contact
- pt data (name age, marital status…)
- allergies
- med orders
- med diagnosis, list in priority
- activities not allowed

a quick review of whats going on

31
Q

What is a flow sheet/ forms?

A

vertical or horizontal columns for recording dates and times and related assessment and intervention info:

  • vitals
  • intake and output
  • assessment
32
Q

Which of these is part of the nurse’s progress notes/ narrative?

  • pts condition, problems and complaints
  • interventions
  • pts response to intervention
  • achievement of outcomes
  • additional assessments
  • report given and received
  • vital signs
A

pts condition, problems, and complaints

interventions

pts response to intervention

achievement of outcome

additional assessments

report given and received ( time, nurse name, important info )

33
Q

Which one of these are components of good documentation?

  • Who
  • what
  • when
  • where
  • why
  • how
  • outcome
A

who
what (did you find)
when ( did it happen )
where (did it happen)
how (did it happen)
outcome (what was the result)

34
Q

Which of these are specific aspects of care?

  • critical diagnostic results
  • fall reduction
  • infection prevention
  • medications and reconciliation of meds (pts history)
  • non-confrorming pt behavior
  • pain assessment and management
  • restraints
  • skin care
  • suicide
A

all of it

Exam 3 (2 decks)

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