Documentation

Question 1

SOAP/SOAPIE/SOAPIER

Answer 1

•Subjective & Objective data
•Assessment
•Plan
•Intervention
•Evaluation
•Revision

Question 2

Kardex

Answer 2

•summary worksheet reference of basic info
-patient data
-medical diagnoses
-allergies
-code status
-medical orders
-activities permitted

Question 3

DAR

Answer 3

-data
-action
-response

Question 4

Report and document

Answer 4

-signs & symptoms
-nursing care rendered
-administration of medications
-client responses
-healthcare team members

Question 5

Signs are

Answer 5

Objective (fact)

Question 6

Purpose of medical records

Answer 6

-communication
-monitoring
-education
-research
-continuity of care
-reimbursement compliance

Question 7

The chart is a

Answer 7

-witness
-a detailed account of the real time facts

Question 8

Documentation should be

Answer 8

-factual
-accurate
-complete
-current
-organized
*no assumptions or opinions

Question 9

Symptoms are

Answer 9

Subjective (use quotations)

Question 10

Accurate

Answer 10

-exact measurements
-clear
-understandable
-correct spelling
-standard abbreviations only
-timed, dated with signature and credentials

Question 11

Factual

Answer 11

-objective
-subjective
-descriptive

Question 12

Complete

Answer 12

-condition change (onset, duration, location, description)
-do not leave blanks (use N/A)
-communication with patient and family

Question 13

Current

Answer 13

-real time or ASAP
-time of occurrences
-military time
-never pre-time, pre-date, pre-chart (this is illegal falsification of record)

Question 14

Organized

Answer 14

-chronological order
-clear
-concise
-complete sentences not needed

Question 15

The chart must reflect an accurate, clear, and comprehensive picture of:

Answer 15

-patients needs
-nurses interventions
-patient outcome

Question 16

Avoid terms like:

Answer 16

-accidentally
-apparently
-appears
-assume
-confusing
-could be
-may be
-miscalculated
-mistake
-somehow
-unintentionally
-normal
-good
-bad

Question 17

Narrative

Answer 17

-written in order of patient experiences
-details patients care, status, nursing interventions, activities, psychosocial context & response to treatment

Question 18

PIE

Answer 18

Problem
Intervention
Evaluation
-nursing focused vs medical focused
-eliminates need for seperate care plan

Question 19

Communication

Answer 19

-multi-disciplinary
-critical for continuity of care and risk reduction

Question 20

Documentation

Answer 20

-who
-what (complaint, care provided)
-when (time)
-where (where was treatment/meds given)
-how (how was treatment completed & how did the pt tolerate it)
-outcome

Question 21

Documentation “don’t”

Answer 21

-don’t document a patient problem without charting what you did about it
-don’t alter a patients record
-don’t write imprecise descriptions
-don’t what what someone else heard, felt, or smelled

Question 22

Documentation
Paper Charting

Answer 22

-print or cursive
-legible
-blue or black ink
-NEVER use white-out
-NEVER use erasable ink
-NEVER obliterate
-NEVER erase- NO pencils

Question 23

Flow Sheets

Answer 23

-Columns for recording dates and times of related assessment and intervention information:
•vital signs
•intake and output
•assessment