Documentation

Question 1

Measure used to maintain confidence and secure components of client records

Answer 1

Documentation

Question 2

Generally, health personnel communicate through ___, ___, and ___.

Answer 2

discussion, reports, and records.

Question 3

A ___ as informal oral consideration of a subject by two or more healthcare personnel to identify a problem or establish strategies to resolve a problem.

Answer 3

discussion

Question 4

• also called a chart or client record, is a formal, legal document that provides evidence of a client’s care and can be written or computer based.

Answer 4

record

Question 5

Although health care organizations use different systems and forms for documentation, all client records have ___ ___.

Answer 5

similar information

Question 6

The process of making an entry on a client record is called ___, ___, or ___.

Answer 6

recording, charting, or documenting.

Question 7

In addition, The Joint Commission requires client record documentation to be ___, ___, ___, ___, and ___ to
the client.

Answer 7

timely, complete, accurate, confidential, and specific

Question 8

Health care reform has been pivotal in the process of increasing the use of the ____.

Answer 8

electronic health record (EHR)

Question 9

ETHICAL AND LEGAL CONSIDERATIONS

The American Nurses Association Code of Ethics (2001) states that “____” (p. 12).

Answer 9

“..the nurse has a duty to maintain confidentiality of all patient information”

Question 10

The ___ ___ is also protected legally as a private record of the client’s care.

Answer 10

client’s record

Question 11

Access to the ___ is restricted to health professionals involved in giving care to the client.

Answer 11

record

Question 12

The ____ or ____ is the rightful owner of the client record.
This does not, however, exclude the client’s rights to the same records.

Answer 12

institution, agency

Question 13

Changes in the laws regarding the client privacy became effective on ____.

Answer 13

April 14, 2003

Question 14

The new HIPAA regulations maintain the privacy and confidentiality of ____.

Answer 14

protected health information (PHI)

Question 15

HIPAA refers to the _____.

Answer 15

Health Insurance Portability and Accountability Act of 1996.

Question 16

____ is identifiable health information that is transmitted or maintained in any form or medium, including verbal discussions, electronic communications with or about clients, and written communications (Hebda & Czar, 2013).

Answer 16

PHI

Question 17

For purposes of ____ and ____, most agencies allow student and graduate health professionals access to client records.

Answer 17

education, research

Question 18

The records are used in ___, ___, ___, ___, and ____.

Answer 18

client conferences, clinics, rounds, client studies, and written papers.

Question 19

The ____ or ____ is bound by a strict ethical code and legal responsibility to hold all information in confidence.

Answer 19

student, graduate

Question 20

It is the responsibility of the ___ or ___ to protect the client’s privacy by not using a name or any statements in the notations that would identify the client.

Answer 20

student, health professional

Question 21

This rule governs the security of electronic PHI. Became mandatory in 2005.

Answer 21

Security Rule of HIPAA

Question 22

SUGGESTION TO ENSURE CONFIDENTIALITY

Answer 22

1. A personal password is required to enter and sign off computer files, do not share this password with anyone, including other health team members,
2. After logging in, never leave a computer terminal unattended,
3. Do not leave client information displayed on the monitor where others may see it,
4. Shred all unneeded computer -generated worksheets
5. Know the facility’s policy and procedure for correcting an entry error.
6. Follow agency procedures for documenting sensitive material, such as a diagnosis of AIDS.
7. Information technology (IT) personnel must install a firewall to protect the server from unauthorized access.

Question 23

PURPOSE OF CLIENT’S RECORDS

Answer 23

• communication
• planning client care
• auditing health agencies
• research, education
• reimbursement
• legal documentation
• health care analysis

Question 24

COMMUNICATION
• The ___ serves as the vehicle by which different health professionals who interact with a client communicate with each other
• This prevents ___, ___, and ___ in client care

Answer 24

record

fragmentations, repetition, and delays

Question 25

PLANNING CLIENT CARE
• Each health professional uses data from the client’s record to plan care for that client.

• Nurses use ___ and ___ to evaluate the effectiveness of the nursing care plan.

Answer 25

baseline and ongoing data

Question 26

An ____ is a review of client records for quality assurance purposes.

Answer 26

audit

Question 27

____ such as The Joint Commission may review client records to determine if a particular health agency is meeting its stated standards.

Answer 27

Accrediting agencies

Question 28

• The information contained in a record can be a valuable source of data for ____.
• The treatment plans for a number of clients with the same health problems can yield information helpful in treating other clients.

Answer 28

research

Question 29

Documentation also helps a facility receive ____ from the federal government.

Answer 29

reimbursement

Question 30

For a facility to obtain payment through Medicare, the client’s clinical record must contain the correct ___ codes and reveal that the appropriate care has been given.

Answer 30

diagnosis related group (DRG)

Question 31

____, such as DRGs, are supported by accurate, thorough recording by nurses.

Answer 31

Codable diagnosis

Question 32

The ____ is a legal document and is usually admissible in court as evidence.

Answer 32

client’s record

Question 33

In some jurisdictions, however, the record is considered ____ as evidence when the client objects, because information the client
gives to the primary care provider is
confidential.

Answer 33

inadmissible

Question 34

HEALTH CARE ANALYSIS
• Information from records may assist health care planners to identify agency needs, such as ___ and ____.
• ____ can be used to establish the costs of various services and to identify those services that cost the agency money and those that
generate revenue.

Answer 34

overutilized and underutilized hospital services

Records

Question 35

DOCUMENTATION SYSTEM

Answer 35

• the source-oriented record
• the problem-oriented medical record;
• the problems, interventions, evaluation (PIE) model:
• focus charting;
• charting by exception (CBE);
• computerized documentation; and
• case management

Question 36

The traditional client record is a ____.

Answer 36

source - oriented record

Question 37

Each person or department makes notations in a separate or sections of the client’s chart.

Answer 37

Source - Oriented Record

Question 38

In this type of record, information about a particular problem is distributed throughout the record.

Answer 38

source - oriented record

Question 39

• Narrative charting is ____.
• It consists of ____.
• There is _____.
• Today, _____.
• Narrative recording ____.
• Many agencies ____.
• When using narrative charting, ____.
• Using the ____.

Answer 39

• Narrative charting is a traditional part of the source-oriented.
• It consists of written notes that Include routine care, normal findings, and client problems.
• There is no right or wrong order to the information, although chronologic order is frequently used.
• Today, few institutions use only narrative charting.
• Narrative recording Is being replaced by other systems, such as charting by exception and focus charting.
• Many agencies combine narrative charting with another system. For example, an agency using a charting-by-exception system may use narrative charting when describing abnormal find
• When using narrative charting, it is important to organize the information in a clear, coherent manner.
• Using the nursing process or a framework is one way to do this.

Question 40

• Source-oriented records are convenient because ____.
• The disadvantage is ____.
• This can lead to ____.

Answer 40

• Source-oriented records are convenient because care providers from each discipline can easily locate the forms on which to record data and it is easy to trace the information
specific to one’s discipline.
• The disadvantage is that information about a particular client problem is scattered throughout the chart, so it is difficult to find chronologic information on a client’s problems and progress.
• This can lead to decreased communication among the health team, an incomplete picture of the client’s care, and a lack of coordination of care.

Question 41

PROBLEM-ORIENTED MEDICAL RECORD (POMR or POR)
• Established by _____.
• Members of the ____.
• Plans for ____.

Answer 41

• established by Lawrence Weed in the 1960s, the data are arranged according to the problems the client has rather than the source of the
information.
• Members of the health care team contribute to the problem list, plan of care, and progress notes.
• Plans for each active or potential problem are drawn up, and progress notes are recorded for each problem.

Question 42

THE ADVANTAGE OF POMR:
• (a)
• (b)

ITS DISADVANTAGES:
• (a)
• (b)
• (c)

Answer 42

• (a) it encourages collaboration and
• (b) the problem list in the front of the chart alerts caregivers to the client’s needs and makes it easier to track the status of each problem.

• (a) caregivers differ in their ability to use the required charting format,
• (b) it takes constant vigilance to maintain an up-to-date problem list, and
• (c) it is somewhat inefficient because assessments and interventions that apply to more than one problem must be repeated…

Question 43

FOUR BASIC COMPONENTS OF POMR:

Answer 43

1. Database
2. Problem list
3. Plan of Care
4. Progress Notes

Question 44

DATABASE consists of:
• all information _____.
• It includes the:
°
°
°
°
°

Answer 44

• all information known about the client when the client first enters the health care agency.
• It includes the:
o nursing assessment,
o the primary care provider’s history,
o social and family data, and
o the results of the physical examination and baseline diagnostic tests.
o Data are constantly updated as the client’s health status changes

Question 45

PROBLEM LIST
• The problem list is ____.
• It is usually kept at ____.
• Problems are _____.
• All caregivers may ____.
• Primary care providers write ____.

Answer 45

• The problem list is derived from the database.
• It is usually kept at the front of the chart and serves as an index to the numbered entries in the progress notes.
• Problems are listed in the order in which they are identified, and the list is continually updated as new problems are identified and others
resolved.
• All caregivers may contribute to the problem list, which includes the client’s physiological, psychological, social, cultural, spiritual, developmental, and environmental needs.
• Primary care providers write problems as medical diagnoses, surgical procedures, or symptoms; nurses write problems as nursing
diagnoses.

Question 46

PLAN OF CARE
• The initial list of ____.
• Care plans are ____.
• Primary care providers write ____.
• The written plan in ____.

Answer 46

• The initial list of orders of plan of care is made with reference to the active problems
• Care plans are generated by the individual who lists the problems
• Primary care providers write physician’s orders or medical care plans; nurses write nursing orders or nursing care plants.
• The written plan in the record is listed under each problem in the progress notes and is not isolated as a separate list of orders.

Question 47

PROGRESS NOTES
• A progress notes in ____.
• Progress notes are _____.
• For example, ____.

Answer 47

• A progress note in the POMR is a chart entry made by all health professionals involved in a client’s care; they all use the same type of sheet for notes.
• Progress notes are numbered to correspond to the problems on the problem list and may be lettered for the type of data.
• For example, the SOAP format is frequently used.

Question 48

SOAP:

Answer 48

Subjective Data
Objective Data
Assessment
Planning

Question 49

SUBJECTIVE DATA:
OBJECTIVE DATA:
ASSESSMENT:
• Assessment is ____.
• During the ____.
PLANNING:
• The plan is ____.
• The initial plan is ____.
• All subsequent plan, ____.

Answer 49

SUBJECTIVE DATA
• verbalized by the client
• included only when it is important and relevant to the problem
OBJECTIVE DATA
• IPPA,
• Vitals signs, and labs and diagnostic results
ASSESSMENT
• Assessment is the interpretation or conclusions drawn about the subjective and objective data.
• During the initial assessment, the problem list is created from the database, so the “A” entry should be a statement of the problem.
PLANNING.
• The plan is the plan of care designed to resolve the stated problem.
• The initial plan is written by the person who enters the problem into the record.
• All subsequent plans, including revisions, are entered into the progress notes.

Question 50

SOAPIER:

Answer 50

Subjective Data
Objective Data
Assessment
Planning
Interventions
Evaluation
Revision

Question 51

PIE:

Answer 51

Problem
Interventions
Evaluation

Question 52

PIE MODEL
• This system consists of ____.
• The flow sheet uses ____.
• The time parameters for ____.
• In a hospital intensive care unit, ____.
• After the assessment, ____.
• If there is ____.

Answer 52

• This system consists of a client care assessment flow sheet and progress notes.
• The flow sheet uses specific assessment criteria in a particular format, such as human needs or
functional health patterns.
• The time parameters for a flow sheet can vary from minutes to months.
• In a hospital intensive care unit, for example, a client’s blood pressure may be monitored by the minute, whereas in an ambulatory clinic a client’s blood glucose level may be recorded once a month.
• After the assessment, the nurse establishes and records specific problems on the progress notes, often using NANDA diagnoses to word the problem.
• If there is no approved nursing diagnosis for a problem, the nurse develops a problem statement using NANDA International’s three-
part format

Question 53

FOCUS CHARTING
• Focus charting describes ____.
• The principal advantage of ____.
• The focus charting system provides ____.
• It also provides a ____.

Answer 53

• Focus charting describes the patient’s perspective and focuses on documenting the patient’s current status, progress towards goals and response to interventions.
• The principal advantage of focus charting is in the holistic emphasis on the patient and his/her priorities including ease in charting.
• The focus charting system provides a holistic perspective of the client and the client’s needs.
• It also provides a nursing process framework for the progress notes (DAR).

Question 54

PURPOSE OF FOCUS CHARTING
• Focus charting brings ____.
• Instead of a ____.
• The focus might be ____.
• Topics that may ____.
• D or may be a _____.

Answer 54

• Focus charting brings the focus of care back to the patient and the patients’ concerns.
• Instead of a problem list or list of nursing and medical diagnosis, a focus column is used that incorporates many aspects of patient and patient care.
• The focus might be patient problem, or need.
• Topics that may appear in the focus column include patients’ concerns and behaviors; therapies and responses; significant events such as teaching, consultation, monitoring,
management of activities of daily living or assessment of functional health patterns.
• D or may be a condition, a nursing diagnosis, a sign or symptom, an acute change in the client’s condition, or client strength.

Question 55

DAR:

Answer 55

Data
Action
Response

Question 56

THE NARRATIVE PORTION OF FOCUS CHARTING INCLUDES (DAR)
DATA
• this category reflects the ____.
• Both _____.
ACTION
• planning and ____.
• It may also include ____.
RESPONSE
• reflects the ____.

Answer 56

DATA
• this category reflects the assessment phase of the nursing process and consists of observations of client status and behaviors, including data from flow sheets (e.g., vital signs,
pupil reactivity).
• Both Subjective and objective data are written here.
ACTION
• planning and implementation and includes immediate and future nursing actions.
• It may also include any changes to the plan of care.
RESPONSE
• reflects the evaluation phase of the nursing process and describes the client’s response to any nursing and medical care.

Question 57

OBJECTIVES: (Focus Charting)
• To easily ___
• To facilitate ___
• To improve
• To improve

Answer 57

• To easily identify critical patient issues/concerns in the progress notes.
• To facilitate communication among all disciplines.
• To improve time efficiency with
documentation
• To improve concise entries that would not duplicate patient information already provided on flowsheet / checklist.

Question 58

GENERAL GUIDELINES
• Focus charting must ____.
• Focus charting must ____.
• Indicate the ____.
• Separate the ____:
° Focus note _____.
° DAR on ____.
• Follow the ____.
• For eight hours shift, ____.
• For twelve hours shift, ____.
• Sign name for ____.
• Document only ____.
• Document patient’s status on ____.
• Data is the _____.
• Action describes the ____.
• Response describes the ____.

Answer 58

• Focus charting must be Evident at least once every shift.
• Focus charting must be patient- oriented not nursing task- oriented.
• Indicate the date and time of entry on the first column.
• Separate the topic words from the body of notes:
o Focus note written on the second column.
o Data, Action and Response on the third column
• Follow the do’s of documentation.
• For eight hours shift, use blue or black ink for morning and afternoon shift, red ink for night shift (depending on the Hospital policy)
• For twelve hours shift, use blue or black ink for morning and red ink for night shift (depending on the Hospital policy)
• Sign name (e.g. Michelle Tolibas, RN) for every time entry.
• Document only patient’s concern and / or plan of care e.g. health per shift, hence, general notes are allowed.
• Document patient’s status on admission, for every transfer to/from another unit or discharge
• Data is the subjective and/or objective information supporting the stated focus or describing the observation at the time of a significant event.
• Action describes the nursing interventions (independent, basic and perspective) past, present or future.
• Response describes the patient

Question 59

SPECIFIC GUIDELINES
• Begin with ____.
• Include ____.
• Establish a ____.
• Document the ____.
• Focus identifies the ____.

Answer 59

• Begin with comprehensive assessment of the patient using inspection, palpation, percussion, and auscultation (IPPA.)
• Include in the assessment, collection of information from the patient, family, existing health records (such as checklist/flow sheets, laboratory results and other health care providers).
• Establish a focus of care, to be addressed in the Progress Notes.
• Document the four elements of focus charting as necessary, wherein:
• Focus identifies the content or purpose of the narrative entry and is separated from the body of the notes in order to promote easy data retrieval and communication.

Question 60

DATA
• Data is the _____.

ACTION
• describes the ____.

Response
• describes the ____.
• outcome/response to ____.

Answer 60

DATA
• Data is the subjective and/or objective information supporting the stated focus or describing the observation at the time of a significant event.

ACTION
• describes the nursing interventions
(independent, basic and perspective) past, present or future.

RESPONSE
• describes the patient
• outcome/response to interventions or describes
how the care plan goals have been attained.

Question 61

FOCUS NOTE IS NECESSARY:
• To describe a _____.
• To identify an _____.
• To document a ____.
• To document an ____.
• To document a ____.
• To document an ____.
• Describe all ____.
• To identify the ____.
• To best describe ____.
• This happens ____.
• Data statements contain ____.
• Action statements contains ____.
• Patient outcome are ____.
• Data, Action, Response only _____.
• Response statements are ____.
• Information from ____.
• However, _____.
• DATA and Action are _____.

Answer 61

• To describe a patient’s problem/ focus/ concern from the care plan - when the purpose of the notes is to evaluate progress toward the defined patient outcome from the plan of care.
Examples:
o Self-care,
o Skin integrity,
o Activity tolerance
• To identify an exception to the expected outcome - when the significant finding or an outcome is not expected (the exception).
Examples:
o Wheezes left base
o Nausea
• To document a new finding - when the purpose of the note is to document a new sign or symptom or a new behavior which is the current focus of care.
o These may be “temporary foci” which do not need to be incorporated on the plan of care because they can quickly be resolved.
o Even if you are uncertain whether the sign or symptom is important, it is valuable to communicate, the information to the health care team.
• To document an acute change in patient’s condition - when there has been an event of new patient condition.
Examples:
o Respiratory distress
o Seizure
o Code blue
• To document a significant event or unusual episode in patient care – when
(a) responsibility for patient care changes from one department to another
(b) a significant treatment. Intervention took place.
Examples:
o Admission Pre-(specify procedure)
assessment Post-(specify procedure)
assessment
o Pre-transfer assessment Discharge
planning
o Discharge status Transfusion RBC Begin thrombolytic therapy PRN medication
required
• To document an activity or treatment that was not carried out - when treatment or activity in the flow sheet was not provided to the patient or was different from the standard of care.
• Describe all specific patient/ family (_ning?) -
this is in compliance with a standard of care.
• Information from all these categories (Data, Action, and Response) should be used only as they are relevant or available.
• However, all appropriate information should be included to ensure complete documentation.
• DATA and ACTION are responded at one hour and RESPONSE is not added until later, when the patient outcome is evident.

Question 62

• is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded.

Answer 62

CHARTING BY EXCEPTION

Question 63

• CBE incorporates three key elements (Guido, 2010):

Answer 63

1. Flow Sheets
2. Standards of Nursing Care
3. Bedside access to chart forms

Question 64

1. Flow sheets
   • Examples of flow sheets include ____.
2. Standard of nursing care
   • An agency using CBE must _____.
   • Documentation of care ____.
   • If all of the standards are ____.
   • All exceptions to the standards are ____.
3. Bedside access to chart forms
   • In the CBE system, _____.

Answer 64

1. Flow sheets. Examples of flow sheets include graphic records of a vital sign sheet, a head and face assessment in a daily nursing assessments record, and a Braden assessment of the skin.
2. Standards of nursing care.
   • An agency using BE must develop its own specific standards of nursing practice that identify the minimum criteria for client care regardless of clinical area.
   • Documentation of care according to these specified standards involves only a check mark in the routine standards box on the graphic record.
   • If all of the standards are not
   implemented, an asterisk on the flow sheet is made with reference to the nurses’
   notes.
   • All exceptions to the standards are fully described in narrative form on the nurses’ notes
3. Bedside access to chart forms.
   • In the CBE system, all flow sheets are kept at the client’s bedside to allow immediate recording and to eliminate the need to transcribe data from the nurse’s worksheet to the permanent record.

Question 65

CHARTING BY EXCEPTION
• The advantages to this system are ____.
• Many nurses believe in the ____.
• One suggestion is ____.
• This would then ____.

Answer 65

• The advantages to this system are that it eliminates lengthy, repetitive notes and it makes client changes in condition more obvious, inherent in CBE is the presumption that the nurse did assess the client and determined what responses were normal and abnormal.
• Many nurses believe in the saying “not charted, not done” and subsequently may feel
uncomfortable with the CBE documentation system.
• One suggestion is to write N/A on flow sheets where the items are not applicable and not to leave blank spaces.
• This would then avoid the possible
misinterpretation that the assessment or intervention was not done by the nurse.

Question 66

DOCUMENTING NURSING ACTIVITIES:

Answer 66

Admission Nursing Assessment
Nursing Care Plan
Kardexes
Flow Sheets
Progress Notes
Nursing Discharge/Referral Summaries

Question 67

ADMISSION NURSING ASSESSMENT
• A comprehensive admission assessment, ____.
• The nurse ____.

Answer 67

• A comprehensive admission assessment, also referred to as an initial database, nursing history, or nursing assessment, is completed when the client is admitted to the nursing unit.
• The nurse generally records ongoing assessments or reassessments on flow sheets or on nursing progress notes.

Question 68

NURSING CARE PLANS
• The Joint Commission requires _____.
• Depending on the ____.
• There are ____.
• The traditional care plan is ____.
• The form varies from ____.
• Most forms have three columns:

Answer 68

• The Joint Commission requires that the clinical record include evidence of client assessments, nursing diagnoses and/or client needs, nursing interventions, client outcomes, and evidence of a current nursing care plan.
• Depending on the records system being used, the nursing care plan may be separate from the client’s chart, recorded in progress notes and other forms in the client record, or incorporated into a multidisciplinary plan of care.
• There are two types of nursing care plans: traditional and standardized.
• The traditional care plan is written for each client.
• The form varies from agency to agency according to the needs of the client and the department.
• Most forms have three columns:
o one for nursing diagnoses,
o a second for expected outcomes and
o a third for nursing interventions.

Question 69

• a widely used, concise method of
organizing and recording data about a client, making information quickly accessible to all health professionals.

Answer 69

Kardexes

Question 70

KARDEXES
• The Kardex, is a _____.
• The system consists of a ____.
• Tke Kardex may or may not ____.
• The information on Kardexes may be organized into sections, for examples: ____.

Answer 70

• The Kardex is a widely used, concise method of
organizing and recording data about a client, making information quickly accessible to all health professionals.
• The system consists of a series of cards kept in a portable index file or on computer-generated forms. The card for a particular client can be quickly accessed to reveal specific data,
• The Kardex may or may not become a part of the client’s permanent record. In some organizations it is a temporary worksheet written in pencil for ease in recording frequent changes in details of a client’s care.
• The information on Kardexes may be organized into sections, for examples
o Pertinent Information about the client, such as name, room number, age, admission date, primary care provider’s name, diagnosis, and type of surgery and date
o Allergies
o List of medications, with the date of order and the times of administration for each
o List of intravenous fluids, with dates of Infusions
o List of daily treatments and procedures, such as irrigations, dressing changes,
o postural drainage, or measurement of vital signs
o List of diagnostic procedures ordered, such as x-ray or laboratory tests
o Specific data on how the client’s physical needs are to be met, such as type of diet,
assistance needed with feeding, elimination devices, activity, hygienic needs, and safety precautions

Question 71

• enables nurses to record nursing data quickly and concisely and provides an easy to-read record of the client’s condition over time.

Answer 71

Flow Sheets

Question 72

Flow Sheets
• A flow sheet enables _____.

Answer 72

• A flow sheet enables nurses to record nursing data quickly and concisely and provides an easy to-read record of the client’s condition over time.

Question 73

Flow Sheets: Types or Components

Answer 73

Graphic Record
Intake and Output Record
Medication Administration Record
Skin Assessment Record

Question 74

GRAPHIC RECORD
• This record typically indicates _____.

INTAKE AND OUTPUT RECORD
• All routes of ____.
• outputs are ____.

MEDICATION ADMINISTRATION RECORD
• Medication flow sheets ____.
• Some records also ____.

SKIN ASSESSMENT RECORD
• A skin or wound assessment is ____.

Answer 74

GRAPHIC RECORD
• This record typically indicates body
temperature, pulse, respiratory rate, blood pressure, weight, and, in some agencies, other significant clinical data such as admission or postoperative day, bowel movements, appetite, and activity.
INTAKE AND OUTPUT RECORD
• All routes of fluid intake and all routes of fluid loss
• outputs are measured and recorded on this form.
MEDICATION ADMINISTRATION RECORD,
• Medication flow sheets usually include designated areas for the date of the medication order, the expiration date, the medication name and dose, the frequency of administration and route, and the nurse’s signature.
• Some records also include a place to document the client’s allergies.
SKIN ASSESSMENT RECORD
• A skin or wound assessment is often recorded on a flow sheet such as the one shown

Question 75

• A _______ are completed when the client is being discharged and transferred to another institution or to a home setting where a visit by a community health nurse is required.

Answer 75

NURSING DISCHARGE/REFERRAL SUMMARIES

Question 76

General Guidelines for Recording:

Answer 76

Date and Time
Timing
Legibility
Permanence

Question 77

DATE AND TIME
• Record the time in the _____.

Answer 77

• Record the time in the conventional manner (as, 9;00 am or 3;45 pm) or according to the 24-hour clock (military clock), which avoids confusion about whether a line was am or put

Question 78

TIMING
• As a rule, ____.
• No recording ____.

Answer 78

• As a rule, documenting should be done as soon as possible after an assessment or intervention.
• No recording should be done before providing nursing care.

Question 79

LEGIBILITY
• All entries must ____.
• Hand printing or _____.
• Follow the _____.

Answer 79

• All entries must be legible and easy to read to prevent interpretation errors.
• Hand printing or easily understood handwriting is usually permissible.
• Follow the agency’s policies about handwritten recording.

Question 80

PERMANENCE
• All entries on the ____.
• Dark ink ____.
• Follow the agency’s ____.

Answer 80

• All entries on the client’s record are made in dark ink so that the record is permanent and changes can be identified.
• Dark ink reproduces well on microfilm and in duplication processes.
• Follow the agency’s policies about the type of pen and in used for recording.

Question 81

DOCUMENTATION DO’s

Answer 81

DO’s:
• DO read what other have written before providing care & before charting
• DO time and date all entries
• DO use flow sheet/checklist, Keep information on flow sheet/checklist current
• DO chart as you make observations.
• DO write your own observations and sign and initial every entry
• DO describe patient’s behaviour
• Do use direct patient direct quotes when appropriate
• DO be factual, complete. Record exactly what happens to the patient and care given
• Do draw a single line thru an ERROR, mark this “ERROR” & sign your name
• Do use available line to chart
• DO document patient’s current and response to medical care and treatments.
• Do write legibly
• Do use standard forms
• Do use only approved abbreviation

Question 82

DOCUMENTATION DON’Ts

Answer 82

• DON’T begin charting until you check the name and identifying number on the patient’s chart on each page.
• DON’T chart procedures or chart in advance.
• DON’T clutter notes with repetitive or frequently changing data already chartered on the flow sheet/checklist.
• DON’T make or sign an entry for someone else, do not sign because someone tells you to
• DON’T change an entry, initial every entry
• DON’T label a patient or show bias
• DON’T try to cover up a mistake or accident by inaccuracy or ommision
• DON’T “white out” or erase an error
• DON’T throw away notes with an error on them
• DON’T squeeze in a missed entry or “leave space” for someone else who forgot to chart
• DON’T use meaningless words and phrases such as “good day” or no complain
• DON’T use notebook, paper or pencil