Documentation Flashcards
*EHR pros/cons?
advantage- improved access to info, info is private, faster to document, improved quality of care, enhanced communication and collaboration
disadvantage- expensive, downtime, difficult to onboard staff, lack of integration across different systems
What is focus charting? What are the three sections? Pros/Cons?
Encourages you to view the patient’s status from a positive perspective rather than a problem oriented one. Three columns: time/date, focus/problem, DAR (data, action, response)
pros- addresses clients problems holistically
cons- no common problem list can lead to inconsistent labeling of the focus (problem)
*Discharge planning starts when?
at admission
What are the purposes of documentation? (8)
communication continuity of care QI Planning and Evaluation Legal Record Professional Standards Reimbursement Education/Research
What are the three reasons to use standardized language?
makes nursing visible
supports nursing research
better integration in EHR
What is a source-oriented system? Pros/Cons?
different disciplines document in different sections
pros: easily locate care by a discipline
cons: data is scattered, especially treatments and outcomes
What is a problem-oriented system? Pros/Cons?
organized according to client problems
pros: common problem list, promotes cooperation among team
cons: requires team cooperation and diligence
What is narrative charting?
story of care chronologically.
pros- useful when constructing a timeline of events, like in emergency situations
cons- lack of standardization, slow to write, slow to read
What is PIE charting? Whats one key component missing from it?
Problem, Interventions, Evaluation
Missing: planning phase
What is SOAP(IER) charting?
S-ubjective- what client or family tells you (usually quoted)
O-bjective- factual/measurable clinical findings
A-ssessment- client problems or nursing diagnosis’
P-lan- STG and LTG
I-ntervention- actions performed
E-valuation- effectiveness of interventions
R-evision- changes made to original care plan
What is FACT documentation? What four sections does it implement?
Charting that eliminates the need to chart normal findings. F-flow sheets A- assessment and baseline data C- concise progress notes T- timely entries
What is included in a nursing admission data form?
cc, VS, allergies, meds, ADL status, physical assessment data, discharge planning
What is included in a nursing discharge summary?
time of departure, transportation, name of persons accompanying pt, condition of patient, teaching provided, discharge instructions, followup appts
What is a MAR? What does it include?
Medication Administration Record
chart meds- scheduled, unscheduled (ex: pre-op med), continuous, prn, stat, single-order
drug allergies
med refusal
assessment data required before administration
omitted or delayed administration
*electronic MAR may have med information such as interactions, indication, contraindications, safe dosage
What is an IPOC? What does it map out? What are the advantages?
Integrated Plan of Care:
maps out day by day client goals, outcomes, interventions, treatments
pros- predicts length of stay, monitor costs of care, assists with staffing, eliminates duplicate charting, increases team effort, enhances nurses teaching
