Documentation and Reporting - Unit 1 Flashcards
Documentation - def
The written, legal record of all pertinent interactions with the patient - assessing, diagnosing, planning, implementing, and evaluating.
Patient Record - a ___ of a patient’s health information.
Compilation.
JCAHO specifies that nursing care, data related to patient assessments, nursing diagnoses, nursing interventions, and patient outcomes be permanently integrated into the patient record. T/F?
True!
What are some purposes of patient records?
Communication, care planning, quality review, legal documentation, research, historical documentation, reimbursement, education and decision analysis.
Guidelines for Recording - Timing -
for each notation, documentation of the date and time of the recording and of the assessment or intervention is essential.
Document whenever you want. T/F?
False - do it as soon as possible!
Recording can be done before providing care. T/F?
False! You need to do it ONLY after you’ve done something!
Guidelines for recording - confidentiality - def
The patient’s record is protected legally as a private record of the patient’s care.
Permanence - def - all entries…
all entries on the client’s record are made in dark colored (BLACK) ink so that the record is permanent and changes can be identified.
We don’t need to sign the recording’s. T/F?
False - we do need to!
Accuracy - it is essential that…
all notations on the record be accurate and correct.
We need to quote ___, avoid __ words, spell ___, draw a line through an __ and initial it, and draw a line through all ___ spaces.
Direct.
Avoid general words.
error.
blank.
Recording - sequence - the nurse documents events in the order in which they…
occur!
Appropriateness - only information that pertain to the patient’s health problem and care is recorder. T/F?
True!
Don’t use standard terminology - T/F?
False - use it!
Source Oriented Record - most or least common?
Most common!
Problem Oriented Medical Records - like a care plan. T/F?
True!
PIE - Problem, Intervention, Evaluation - what is it?
Kind of like nursing progress.
Focus Charting - def
focusing on one thing! Problem? We don’t focus holistically!
Charting by exception - what does it mean?
We chart only what’s wrong!
Case management/computerized records - are these actual charts?
Yup!
What are some formats for nursing documentation?
Initial nursing assessment (lengthy), Kardex (little cards), nursing plan, critical/collaborative pathways (like certain disease? means certain things are done), flow sheets, progress notes, discharge and transfer summary and home healthcare documentation.
What are some components of flow sheets?
Graphic sheet, 24-hour fluid balance record, medication record (MAR), and 24 hour patient care record.
One in __ malpractice suits are determined on the basis of the patient record.
1/4.
What are some problems with documentation content?
The content is not in accordance with professional or healthcare organization standards, the content is incomplete, the content does not reflect patient needs, the content implies attitudinal bias, etc.
Documentation mechanics? What are some problems?
Lines between entries, countersigning documentation, tampering, sloppiness, dates and time omitted or inconsistent, transcription errors, etc.
Report - def
The oral, written, or computer based communication of patient data to others.
What are some types of reports?
Change of shift report, telephone report, telephone orders, transfer and discharge reports, reports to family, incident reports, etc.
