Documentation

Question 1

ANA Code of Ethics

Answer 1

“the nurse has a duty to maintain confidentiality of all patient information” -nursing students held to the same standard

Question 2

Not welcome in the chart if…

Answer 2

not involved in their care

Question 3

Who owns medical records?

Answer 3

The agency (hospital or facility)

Question 4

Who has rights to medical records?

Answer 4

Patients

Question 5

PHI

Answer 5

Protected Health Information

• identifiable health information that is transmitted or maintained.
• Includes written, verbal, electronic info

Question 6

EMRs or EHRs must have…

Answer 6

firewall

Question 7

Purposes of health care records

Answer 7

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

Question 8

Source-oriented record

Answer 8

• traditional type of record
• organized by departments (admission, physicians, nursing, radiology, etc.)

Question 9

Advantage of source-oriented records

Answer 9

easy to locate information from each discipline

Question 10

Disadvantage of source-oriented records

Answer 10

data from specific problem scattered throughout chart

Question 11

problem-oriented medical record

Answer 11

data in chart arranged to patient problems

• database
• problem list
• plan of care
• progress notes

Question 12

Advantage of problem-oriented records

Answer 12

• team collaborates to create plan
• provides quick identification of recognized problems

Question 13

Disadvantage of problem-oriented records

Answer 13

• charting may be lengthy, redundant
• problem list may not be kept up to date

Question 14

Narrative charting

Answer 14

• notes that include routine care, normal findings, and patient problems
• written in an abbreviated story form
• may be used when charting abnormal findings
• use nursing process to organize data

Question 15

SOAP/SOAPIE/SOAPIER note

Answer 15

• S - subjective; what the client says, in quotes or paraphrased without nurse’s opinion
• O - objective; what nurses observes or measures
• A - assessment; nursing diagnosis or problem
• P - plan; what will be done about the problem
• I - intervention; actions taken for problem
• E - evaluation; how did client respond to intervention?
• R - revision; changes made to plan of care

Question 16

PIE Charting

Answer 16

• P - Problem
• I - Intervention
• E - Evaluation

omits the planning phase of nursing process

Question 17

Focus charting

Answer 17

focus may be a condition, nursing diagnosis, patient behavior, sign and symptom, or acute change in patient condition

• D - data
• A - action
• R - response

Question 18

Charting by Exception (CBE)

Answer 18

documentation system in which only significant findings or deviations from norms are recorded

Question 19

Components of CBE

Answer 19

1. flow sheets
2. standards of nursing care
3. bedside access to charts

Question 20

Advantages of CBE

Answer 20

• elimination of lengthy repetitive notes
• flowsheets for specific entities
• reports changes in client condition
• easier to read and pick out problem areas

Question 21

Disadvantages of CBE

Answer 21

• some nurses may feel if it is not charted, it is not done
• may want to fill in blank spaces with N/A
• may not pick up subtle changes in condition
• must know normal standards of care for healthcare organization - minimum criteria

Question 22

CBE presumes…

Answer 22

all systems are assessed

Question 23

Risks of CBE

Answer 23

• minimizing documentation is risky
• little description in notes could fail to alert other clinicians of potential problems
• no mention of periodic patient checks could be construed as negligence

Question 24

Critical pathways

Answer 24

• used to document care
• emphasizes quality and cost-effective care given in pre-determined length of time

Question 25

Under critical pathway, if goal is met…

Answer 25

no further charting needed

Question 26

Under critical pathway, if goal is not met…

Answer 26

called a variance

Question 27

variance

Answer 27

unexpected occurence

Question 28

Guidelines for effective documentation

Answer 28

• time and date
• document ASAP after assessment/intervention
• legibility
• permanence
• accepted terminology
• accuracy
• appropriateness
• completeness
• conciseness
• legal prudence

Question 29

Recording Do’s

Answer 29

• chart any change in patient condition
• use factual information
• chart all teaching
• chart patient’s words in quotes or paraphrase
• chart all patient responses to interventions

Question 30

Recording Don’ts

Answer 30

• do not leave blank spaces
• do not chart in advance
• do not use vague terms
• do not chart for someone else
• do not use white out or alter client records
• do not use bias or perceptions in charting

Question 31

SBAR

Answer 31

tool for nurses to communicate patient needs or changes in patients condition with physician/ARNPs

Question 32

handoff communication

Answer 32

transfer of communication during transition of care

• ER RN to floor RN
• Hospital RN to rehab RN
• Change of shift report

Question 33

Change of shift report

Answer 33

• basic info: name, age, dx, surgery or diagnostic tests
• significant changes in condition - follow nursing process
• provide info about nursing care and provider ordered care
• clearly state priorities of care
• concise - no unneeded info

Question 34

Telephone reports

Answer 34

• pt name, dx
• changes in assessment
• vital signs
• significant labs
• document time & date, name of person or recieving report

Question 35

Telephone orders

Answer 35

• check agency policy
• may be only RNs can recieve telephone orders
• write down order and read back
• may have second RN listen to order