Documentation Flashcards
1
Q
What is the bare minimum to report?
A
- Signs and symptoms
- Nursing Care Rendered
- Administration of Medications
- Client’s responses
- Healthcare team members
2
Q
Why is documentation very important?
A
It is legal information that is the only thing that can help as proof in legal battles, its a witness in other words
3
Q
What are the ANA’s expectations for documentation?
A
- Report relevant data
- Problems and issues
- Report expected outcomes and goals
- Use standardized language and terminology
- Any modification
- Coordination of care
- Evaluation of results
4
Q
What’s the purpose of medical records?
A
- Communication: Between both pt and family
- Monitoring
- Education
- Research
- Continuity of care
- Reimbursement
5
Q
Why is communication important?
A
- Important for continuity and risk education
6
Q
What is a good simple format to follow for documentation?
A
- Who
- What: Complaints, care, etc.
- When
- Where: Where was the event or even where was medication applied
- How: How was it done or how did they react?
7
Q
What must documentation be?
A
- Factual
- Can be objective or subjective when pt says something just put that in quotes and be descriptive
- Accurate
- Exact measurements
- Clear and understandable
- Correct spelling with standard abbreviations only
- Timed and dated
- Complete
- Changes in condition
- NO BLANKS, USE N/A
- Any communication
- Current
- Never pre-time, pre-date, or pre-chart something, it is illegal falsification
- Organized
- Chronological order
- Complete sentences are not needed
- Cannot contain assumptions or opinions
8
Q
If you walk in and see a pt on the ground, what can you document?
A
- Only what you know, if you saw him on the ground then all you can say is “Found PT on ground”
9
Q
The chart musty be a picture of?
A
- Pt needs
- Nurse interventions
- Pt outcome
10
Q
What are some terms you should avoid when documenting?
A
- Accidentally
- Appears
- Assume
- Confusing
- Could be or may be
- Mistake
- Somehow
- Normal
11
Q
What are some “Don’ts” of documentation?
A
- Don’t chart an issue unless you chart what you did about it
- Never alter records, its a crime
- No imprecise descriptions like “soaked”
- Don’t chart what someone else heard or reported unless its critical information, then say that they reported it
- Never label a pt behavior like “Rude” or “Obnoxious”
- Don’t use white-out, erasable ink or pencils
- Never obliterate writing
12
Q
Types of Documentation?
A
- Narrative: Written in order of PT experiences
- Problem Intervention Evaluation (PIE): Nursing Focused vs Medical focused and eliminates need for separate care plan
- SOAPIER: Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision
- DAR: Data, Action, Response
- Flow Sheets and Graphic sheets
- Medication Admission Records
- Kardex
13
Q
What is a Kardex?
A
- A summary sheet that holds basic info that’s not usually on record
14
Q
What is a flow sheet?
A
Columns for recording dates and times of related assessment
15
Q
What is in a Nurse’s progress Notes?
A
- Narrative charting
- Pt condition and other info
- Interventions and response
- Outcomes
- Additional Assessment
- Report Given and received
