Documentation

Question 1

Purpose of a medical record (7 things)

Answer 1

Communication
Legal documentation
Education
Reimbursement 
Education
Research
Auditing/monitoring

Question 2

Why the shift to electronic documentation?

Answer 2

decrease cost, improve pt care

Question 3

What is confidential?

Answer 3

EVERYTHING

Question 4

What are the 7 things you need to have an assessment of when documenting?

Answer 4

Physical
Psychological 
Environmental
Self care
Knowledge level
Discharge planning
Pt & family planning

Question 5

Guidelines for QUALITY documentation (5)

Answer 5

Factual-objective
Accurate-clear, easy to read
Complete
Current
Organized

Question 6

3 Methods of reporting

Answer 6

Charting by Exception (CBE)
Critical (clinical) Pathways
Case Management Plans

Question 7

Methods of documentation

Answer 7

Narrative (traditional method)

Problem-oriented medical record (POMR)

Question 8

this form of documentation has details in step by step fashion–rare

Answer 8

Narrative method of documentation

Question 9

This form of documentation has databases, the patient’s problem list, the current care plan, and the progress notes meaning what went on throughout your shift.

Answer 9

POMR

Question 10

SOAP

Answer 10

Subjective, objective, assessment (diagnosis), Plan

Question 11

SOAPIE

Answer 11

Subjective, objective, assessment, plan, intervention, evaluation (similar to nursing assessment)

Question 12

PIE

Answer 12

Problem (diagnosis), intervention (what was done in order to address problem), evaluation

Question 13

Focus Charting (DAR) focuses on client needs from variety of perspectives

Answer 13

Data, action, response

Question 14

Charting by Exception (CBE) is commonly used in

Answer 14

electronic documentation
checking off “normal” box
charting only if something is abnormal
flowsheets, checklists

Question 15

Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient

Answer 15

Incident or occurence reports

Question 16

What are discouraged in hospital setting?

Answer 16

verbal orders (VO)

Question 17

Common Record-Keeping Forms

Answer 17

Admission nursing history form
Flow sheets and graphic records
Patient care summary
Standardized care plans or clinical care guidelines (CPGs)
Discharge summary forms

Question 18

Preprinted, established guidelines used to care for patients who have similar health problems

Answer 18

Standardized care plans or clinical care guidelines (CPGs)

Question 19

Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems

Answer 19

Admission nursing history form

Question 20

Help team members quickly see patient trends over time and decrease time spent on writing narrative notes

Answer 20

Flow sheets and graphic records

Question 21

Most recent data
Put in patient chart if needed
Typically printed out once a day

Answer 21

Patient care summary

Question 22

Documentation needs to conform to standards of the _______ & _____ to maintain institutional accreditation and minimize liability

Answer 22

National Committee for Quality Assurance (NCQA) & TJC