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
What is an occurrence/incident report? How to write one?
formal record of an unusual event or accident that is NOT part of the clients record Includes: client, date, time, location describe incident in objective terms quote client or persons involved identify witnesses avoid drawing conclusions/placing blame document actions taken and responses
What is a MDS as it relates to long-term care?
Minimum Data Set- resident assessment and care screening must done within 14 days of admission and every 3 months thereafter
How can a handoff report be given?
verbally, walking rounds (bedside), audio-recorded
What is SBAR?
Situation- what is happening
Background- reason admitted, status, history, also vitals, meds, labs, code status
Assessment- what you believe the problem to be
Recommendation- what the patient needs
What is a VO?
spoken order usually made during a client emergency
What is a VORB or TORB?
verbal (telephone) order readback
What are the 5 components of a POR?
Database, Problem list, Initial plan, Progress Notes, Discharge Planning
What documentation is required for reimbursement of home healthcare?
monthly summary describing the client’s status and ongoing needs is required which the PCP signs (OASIS)
What is a PACE handoff?
Patient/Problem
Assessment/Actions
Continuing/Changes
Evaluation
