Documentation

Question 1

Written records that reflect on the clients care.
A written evidence on:
● Interactions between health practitioner
● Administration of tests, procedures and education.
● Results of clients response to treatment

Answer 1

Documentation

Question 2

Principles of Documentation (ACTLCOO)

Answer 2

Accuracy
Completeness
Timeliness
Legibility
Consiceness
Objectivity
Organization

Question 3

“What do you want to do?”

Answer 3

Specific

Question 4

“How will you know when you’ve reached it?”

Answer 4

Measurable

Question 5

“Is it in your power to accomplish it?”

Answer 5

Achievable

Question 6

“Can you realistically achieve it?”

Answer 6

Realistic

Question 7

When exactly do you want to accomplish it?”

Answer 7

Timely

Question 8

● The record serves as the vehicle by which different health professionals who interact with a client communicate with each other. This prevents fragmentation, repetition, and delays in client care.

Answer 8

Communication

Question 9

● Each health professional uses data from the client’s record to plan care for that client. A primary care provider, for example, may order a specific antibiotic after establishing that the client’s temperature is steadily rising and that laboratory tests reveal the presence of a certain microorganism. Nurses use baseline and ongoing data to evaluate the effectiveness of the nursing care plan.

Answer 9

Planning Client Care

Question 10

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

Answer 10

Auditing Health Agencies

Question 11

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

Answer 11

Auditing Health Agencies

Question 12

● The information contained in a record can be a valuable source of data for research.

Answer 12

Research

Question 13

● The treatment plans for a number of clients with the same health problems can yield information helpful in treating other clients.

Answer 13

Research

Question 14

● Students in health disciplines often use client records as educational tools. A record can frequently provide a comprehensive view of the client, the illness, effective treatment strategies, and factors that affect the outcome of the illness.

Answer 14

Education

Question 15

● Documentation also helps a facility receive reimbursement from the federal government.
● For a facility to obtain payment through Medicare, the client’s clinical record must contain the correct diagnosis-related group (DRG) codes and reveal that the appropriate care has been given

Answer 15

Reimbursement

Question 16

● The client’s record is a legal document and is usually admissible in court as evidence.
● In some jurisdictions, however, the record is considered inadmissible as evidence when the client objects, because information the client gives to the primary care provider is confidential.

Answer 16

Legal Documentation

Question 17

● Information from records may assist health care planners to identify agency needs, such as overutilized and underutilized hospital services. Records 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 17

Healthcare Analysis

Question 18

● Document the date and time of each recording. This is essential not only for legal reasons but also for client safety.
● Record the time in the conventional manner (c. g- 9.00 AM or 3:15 PM) or according to the 24-hour clock (military clock), which avoids confusion about whether a time was AM or PM

Answer 18

Date and Time

Question 19

● Follow the agency’s policy about the frequency of documenting, and adjust the frequency as a client’s condition indicates; for example a client whose blood pressure is changing requires more frequent documentation than a client whose blood pressure is constant. 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.

Answer 19

Timing

Question 20

● 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

Answer 20

Legibility

Question 21

● 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 ink used for recording.

Answer 21

Permanence

Question 22

• Abbreviations are used because they are short, convenient, and easy to use.
• The most common problems include ambiguity, unfamiliar abbreviations, and look-alike abbreviations.

Answer 22

Accepted Terminology

Question 23

• It is important to use only commonly accepted abbreviations, symbols, and terms that are specified by the agency.

Answer 23

Accepted Terminology

Question 24

● Correct spelling is essential for accuracy in recording. If unsure how to spell word, look it up in a dictionary or other resource book,

Answer 24

Correct Spelling

Question 25

● Each recording on the nursing notes is signed by the nurse making it. The signature includes the name and title
● Some agencies have signature sheet and after signing this signature sheet, nurses can use their initials. With computerized charting, each nurse has his or her own code, which allows the documentation to be identified.

Answer 25

Signature

Question 26

• The client’s name and identifying information should be stamped or written on each page of the clinical record. Before making any entry, check that it is the correct chart. Do not identify charts by room number only; check the client’s name. Special care is needed when caring for clients with the same last name.
• Notations on records must be accurate and correct. Accurate notations consist of facts or observations rather than opinions or interpretations
• When a recording mistake is through it to identify it as made, draw a single line erroneous with your initials or name above or near the line (depending on agency policy). Do not erase, blot out, or use correction fluid. The original entry must remain visible. When using computerized charting, the nurse needs to be aware of the agency’s policy and process for correcting documentation mistakes

Answer 26

Accuracy

Question 27

● Document events in the order in which they occur, for example, record assessments, then the nursing interventions, and then the client’s responses. Update or delete problems as needed.

Answer 27

Sequence

Question 28

● Record only information that pertains to the client’s health problems and care. Any other personal information that the client conveys is inappropriate for the record. Recording irrelevant information may be considered an invasion of the client’s privacy and/or libelous.

Answer 28

Appropriateness

Question 29

● Not all data that a nurse obtains about a client can be recorded. However, the information that is recorded needs to be complete and helpful to the client and health care professionals. Nurses’ notes need to reflect the nursing process.
● Record all assessments, dependent and independent nursing interventions, client problems, client comments and responses to interventions and tests, progress toward goals, and communication with other members of the health team
● Care that is omitted because of the client’s condition or refusal of treatment must also be recorded.
● Document what was omitted, why it was omitted, and who was notified.

Answer 29

Completeness

Question 30

● Recordings need to be brief as well as complete to save time in communication. The client’s name and the word client are omitted. For example, write “Perspiring profusely. Respirations shallow, 28/min.” End each thought or sentence with a period.

Answer 30

Consciseness

Question 31

● Accurate, complete documentation should give legal protection to the nurse, the client’s other caregivers, the health care facility, and the client. Admissible in court as a legal document, the clinical record provides proof of the quality of care given to a client. Documentation is usually viewed by juries and attorneys as the best evidence of what really happened to the client

Answer 31

Legal Prudence

Question 32

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

Answer 32

Traditional Client Record

Question 33

Legal name, birthdate, age, gender…

Answer 33

Admission (face) sheet

Question 34

findings from the initial nutsing history and physical health assessment

Answer 34

Initial Nursing Assessment

Question 35

body temp, PR, RR, BP, DAILY WEIGHT, special measurements, fluid intake, O2

Answer 35

Graphic record

Question 36

activity, diet, bathing, elimination records

Answer 36

Daily Care record

Question 37

skin assessment, fluid balance record

Answer 37

special flow sheets

Question 38

name, dosage, route…

Answer 38

Medication record

Question 39

pertinent assessment, teaching, responses, complaints…

Answer 39

Nurses’ notes

Question 40

past and family medical history…

Answer 40

Medical history and physical examination

Question 41

Medical orders

Answer 41

Physician’s order forms

Question 42

• Narrative recording on separate sheets by each member (source) of the health care team.
• Care is often fragmented, and communication between disciplines is time-consuming.
• Advantages and disadvantages are similar to narrative charting

Answer 42

Source-Oriented Charting

Question 43

• Brief and concise
• Often fragmented
• Similar to narrative charting because of unstructured approach

Answer 43

Source-Oriented/Traditional Charting

Question 44

• 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.

Answer 44

Advantages of Source-Oriented Charting

Question 45

• information about a particular client problem is scattered throughout the chart,
• so, it is difficult to find chronological 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

Answer 45

Disadvantages of SOC

Question 46

• is a traditional part of the source-oriented record
• It is a story format charting that describes the clients status, interventions, treatment and response to treatment
• Write in paragraph form and in chronological order

Answer 46

Narrative Charting

Question 47

• Most flexible and usable in any clinical setting
• It is important to organize the information in a clear, coherent manner.

Answer 47

Narrative Charting

Question 48

• Subjectivity is a common problem

Answer 48

Narrative Charting

Question 49

• 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

Answer 49

Problem Oriented Medical Record

Question 50

(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.

Answer 50

Advantages of POMR

Question 51

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

Answer 51

Disadvantages

Question 52

POMR 4 Basic Components

Answer 52

• Database
• Problem list
• Plan of care
• Progress notes.
• In addition, flow sheets and discharge notes are added to the record as needed

Question 53

• The _____ consists of all information known about the client when the client first enters the health care agency.

Answer 53

Database

Question 54

• It includes the nursing assessment, the primary care provider’s history, social and family data, and the results of the physical examination and baseline diagnostic tests.
• Data are constantly updated as the client’s health status changes.

Answer 54

Database

Question 55

• 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.

Answer 55

Problem List

Question 56

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
* As the client’s condition changes or more data are obtained, it may be necessary to “redefine” problems.
* When a problem is resolved, a line is drawn through it and the number is not used again for that client.

Answer 56

Problem List

Question 57

• The initial list of orders or _____ is made with reference to the active problems.
• Care plans are generated by the person who lists the problems.
• Primary care providers write physician’s orders or medical care plans; nurses write nursing orders or nursing care plans.
• 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.

Answer 57

Plan of Care

Question 58

a _____ 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.
* ________ are numbered to correspond to the problems on the problem list and may be lettered for the type of data

Answer 58

Progress Notes

Question 59

SOAP is an acronym for

Answer 59

• subjective data
• objective data
• assessment
• planning

Question 60

Components: Medical observations

Answer 60

Physician’s progress notes

Question 61

records by clinical specialists and medical

Answer 61

Consultation records

Question 62

labs, xray, CT

Answer 62

Diagnostic Reports

Question 63

started admission and completed on discharge

Answer 63

Client discharge plan and referral summary

Question 64

• consist of information obtained from what the client says.
• It describes the client’s perceptions of and experience with the problem.
• When possible, the nurse quotes the client’s words; otherwise, they are summarized.
• ______are included only when it is important and relevant to the problem

Answer 64

Subjective data

Question 65

• consist of information that is measured or observed by use of the senses (e.g., vital signs, laboratory and x-ray results).

Answer 65

Objective data

Question 66

• 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.
• In all subsequent SOAP notes for that problem, the “A” should describe the client’s condition and level of progress rather than merely restating the diagnosis or problem

Answer 66

Assessment

Question 67

• 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.

Answer 67

The Plan

Question 68

refer to the specific interventions that have actually been performed by the caregiver.

Answer 68

Interventions

Question 69

___ includes client responses to nursing interventions and medical treatments. This is primarily reassessment data.

Answer 69

Evaluation

Question 70

________reflects care plan modifications suggested by the evaluation. Changes may be made in desired

Answer 70

Revision

Question 71

• the nurse identifies and lists client problems; documentation then follows according to the identified problems.

Answer 71

SOAPIER

Question 72

meaning of PIE

Answer 72

Problem, intervention, evaluation

Question 73

• The ____ uses specific assessment criteria in a particular format, such as human needs or functional health patterns

Answer 73

Flow sheet

Question 74

NANDA International’s three-part format:

Answer 74

client’s response, contributing or probable causes of the response, and o characteristics manifested by the client

Question 75

• The _______ eliminates the traditional care plan and incorporates an ongoing care plan into the progress notes.

Answer 75

Pie system

Question 76

• Consist of assessment flow sheets, nurses progress notes and an integrated plan of care
• Eliminates the traditional care plan and incorporates an ongoing care plan.
• Nurse must review all the nursing notes before giving care to determine which problems are current.

Answer 76

PIE CHARTING

Question 77

______ is intended to make the client and client concerns and strengths the focus of care.

Answer 77

focus charting

Question 78

• Three columns for recording are usually used: ______

Answer 78

date and time, focus, and progress notes.

Question 79

______ 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).
* The nurse records both subjective and objective data in this section.

Answer 79

Data

Question 80

______ category reflects planning and implementation and includes immediate and future nursing actions. It may also include any changes to the plan of care

Answer 80

Action

Question 81

______ category reflects the evaluation phase of the nursing process and describes the client’s response to any nursing and medical care

Answer 81

Response

Question 82

Subjective and/or objective information that supports the stated focus or describes the client status at the time of significant intervention

Answer 82

Data

Question 83

Completed or planned nursing interventions based on the nurse’s assessment of the client’s status.

Answer 83

Action

Question 84

Description of the impact of the interventions on client outcomes.
* The focus charting system provides a holistic perspective of the client and the client’s needs.

Answer 84

Response

Question 85

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

Answer 85

Charting by exception (CBE)

Question 86

CBE three key elements

Answer 86

• Flow sheets
• Standards of nursing care
• Bedside access to chart forms

Question 87

EXAMPLES OF ___ include a graphic record, fluid balance record, daily nursing assessments record, client teaching record, client discharge record, and skin assessment record.

Answer 87

Flow sheets

Question 88

• Documentation by reference to the agency’s printed standards of nursing practice eliminates much of the repetitive charting of routine care.
• An agency using CBE must develop its own specific standards of nursing practice that identify the minimum criteria for client care regardless of clinical area. Some units may also have unit-specific standards unique to their type of client.
• 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.

Answer 88

Standards of Nursing care

Question 89

• 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.

Answer 89

Bedside access to chart forms

Question 90

• Nurses use computers to store the clients data base, add new data, create and revise care plans, and documents client progress

Answer 90

Computerized

Question 91

• Is a popular for completing medical records from admission through discharge.
• Benefits:
• Promotes standardization
• Eliminate legibility problems
• Fewer errors made
• Decrease recording time and costs
• Aided communication among team members
• Allows easier access to medical data for education, research and performance improvement.

Answer 91

Computerized charting

Question 92

__________ model emphasizes quality, cost-effective care delivered within an established length of stay.
* This model uses a multidisciplinary approach to planning and documenting client care, using critical pathways
* These forms identify the outcomes that certain groups of clients are expected to achieve on each day of care, along with the interventions necessary for each day.

Answer 92

Case Management

Question 93

usescompuer to store

Answer 93

Computerized

Question 94

popular for completing medical records

Answer 94

Computerized charting

Question 95

manage the huge volume

Answer 95

Electronic health records

Question 96

by voice conversion

Answer 96

automated speech recognition technology