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Fundamentals Exam 3 > Documentation > Flashcards

Documentation Flashcards

1
Q

ANA Code of Ethics

A

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

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2
Q

Not welcome in the chart if…

A

not involved in their care

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3
Q

Who owns medical records?

A

The agency (hospital or facility)

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4
Q

Who has rights to medical records?

A

Patients

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5
Q

PHI

A

Protected Health Information

  • identifiable health information that is transmitted or maintained.
  • Includes written, verbal, electronic info
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6
Q

EMRs or EHRs must have…

A

firewall

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7
Q

Purposes of health care records

A
  • communication
  • planning client care
  • auditing health agencies
  • research
  • education
  • reimbursement
  • legal documentation
  • healthcare analysis
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8
Q

Source-oriented record

A
  • traditional type of record
  • organized by departments (admission, physicians, nursing, radiology, etc.)
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9
Q

Advantage of source-oriented records

A

easy to locate information from each discipline

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10
Q

Disadvantage of source-oriented records

A

data from specific problem scattered throughout chart

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11
Q

problem-oriented medical record

A

data in chart arranged to patient problems

  • database
  • problem list
  • plan of care
  • progress notes
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12
Q

Advantage of problem-oriented records

A
  • team collaborates to create plan
  • provides quick identification of recognized problems
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13
Q

Disadvantage of problem-oriented records

A
  • charting may be lengthy, redundant
  • problem list may not be kept up to date
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14
Q

Narrative charting

A
  • 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
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15
Q

SOAP/SOAPIE/SOAPIER note

A
  • 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
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16
Q

PIE Charting

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

omits the planning phase of nursing process

17
Q

Focus charting

A

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

  • D - data
  • A - action
  • R - response
18
Q

Charting by Exception (CBE)

A

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

19
Q

Components of CBE

A
  1. flow sheets
  2. standards of nursing care
  3. bedside access to charts
20
Q

Advantages of CBE

A
  • elimination of lengthy repetitive notes
  • flowsheets for specific entities
  • reports changes in client condition
  • easier to read and pick out problem areas
21
Q

Disadvantages of CBE

A
  • 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
22
Q

CBE presumes…

A

all systems are assessed

23
Q

Risks of CBE

A
  • 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
24
Q

Critical pathways

A
  • used to document care
  • emphasizes quality and cost-effective care given in pre-determined length of time
25
Q

Under critical pathway, if goal is met…

A

no further charting needed

26
Q

Under critical pathway, if goal is not met…

A

called a variance

27
Q

variance

A

unexpected occurence

28
Q

Guidelines for effective documentation

A
  • time and date
  • document ASAP after assessment/intervention
  • legibility
  • permanence
  • accepted terminology
  • accuracy
  • appropriateness
  • completeness
  • conciseness
  • legal prudence
29
Q

Recording Do’s

A
  • 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
30
Q

Recording Don’ts

A
  • 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
31
Q

SBAR

A

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

32
Q

handoff communication

A

transfer of communication during transition of care

  • ER RN to floor RN
  • Hospital RN to rehab RN
  • Change of shift report
33
Q

Change of shift report

A
  • 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
34
Q

Telephone reports

A
  • pt name, dx
  • changes in assessment
  • vital signs
  • significant labs
  • document time & date, name of person or recieving report
35
Q

Telephone orders

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

Fundamentals Exam 3 (6 decks)

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