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IM 1 > Documentation- Exam 3 > Flashcards

Documentation- Exam 3 Flashcards

1
Q

Relevant data

A

Accurately and in a manner accessible to the interprofessional team

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2
Q

Problems and issues

A

In a manner that facilitates the determination of the expected outcomes and plan

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3
Q

Expected outcomes as..

A

Measurable goals

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4
Q

Discharge happens when

A

On admission

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5
Q

Purpose of records

A

Communication
Legal document
Reimbursement compliance
Education
Research
Auditing and monitoring
Continuity of care

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6
Q

Communication

A

Critical for continuity and risk reduction
- current status/ needs
- progress
- therapies
- consultations
- education
- discharge planning

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7
Q

Documentation needs to be

A

Factual
Accurate
Complete
Current
Organized

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8
Q

You need to be what on documentation

A

Objective
Descriptive
Subjective (quotes)
NO ASSUMPTIONS

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9
Q

Anyone reviewing the chart must be able to understand an accurate, clear and comprehensive picture of

A

Patient needs
Nurses interventions
Patient outcome

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10
Q

When to document

A

As soon as possible
Time or occurrence
Never pre-time

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11
Q

Documentation needs to be in

A

Chronological order
Clear
Concise
To the point
Complete sentences not needed

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12
Q

Avoid these terms

A

Accidentally
Apparently
Appears
Assume
Confusing
Could be
May be
Miscalculated
Mistake
Somehow
Unintentionally
Normal
Good
Bad

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13
Q

Documentation don’ts

A

-Don’t document a patient problem without charting what you did about it
-Don’t alter a pts record
- don’t write imprecise descriptions
- don’t chart what someone else heard
- don’t chart ahead of time

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14
Q

Narrative

A

Written in order of patient experience happens
Provides details in patients care, status, activities, nursing interventions, psychological context and response to treatment

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15
Q

Problem-intervention-evaluation (PIE)

A

Nursing focused instead of medical focused and elongated need to separate care plan

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16
Q

Soap/soapie/soapier

A

Subjective data, objective data, assessment, plan, intervention, evaluation, revision

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17
Q

DAR

A

Data, action, response

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18
Q

Flow sheets

A

Check list - assessment
Vital signs
Intake and output

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19
Q

Medication administration record

A

Scheduled meds
Unscheduled meds
Drug allergies
Single order medications

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20
Q

Kardex

A

Not a permanent record
A summary of pts needs and care

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21
Q

Paper charts

A

Print or cursive
Blue or black ink
Never use white out
Never use erasable ink
Never obliterate
Never erase - no pencils

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22
Q

SBAR

A

Situation
Background
Assessment
Recommendation

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23
Q

Nurses progress
Notes / narrative

A

Patients condition, problems, and complaints
Interventions
Patients response to interventions
Achievement of outcomes
Additional assessment
Report given
Time
Nurses name
Important information

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24
Q

Components of good documentation

A

Who, what, when, where, how, outcome

25
Q

Who

A

The patient

26
Q

What

A

Assessment findings
Patients condition
Care you provided

27
Q

When

A

The time when you provided care

28
Q

Where

A

Where did event take place
Where was the treatment given or medication administered

29
Q

How

A

How was treatment completed
How did the resident tolerate the procedure/ treatment

30
Q

Outcome

A

Outcome of the procedure / treatment

31
Q

Follow up

A

What type of follow up needed

32
Q

Accuracy

A

Exact measurement

33
Q

Specific aspects of care

A

Fall reduction
Infection prevention
Non-conforming and management
Pain assessment and management
Restraints
Skin care
Suicide

34
Q

Notifying provider
Include

A

Include the full name of the provider

35
Q

Notifying provider - note

A

Note the exact time that you notified provider

36
Q

Notifying provider -state

A

State the specific laboratory result, symptom, or other assessment data that you reported

37
Q

Notifying provider - record

A

Record the providers response, using exact words if possible

38
Q

Notifying provider- include

A

Any order the provider gives or when they don’t give orders

39
Q

Notifying provider- pursue

A

If a provider fails to respond to a page, a telephone message, or fails to order an intervention

40
Q

Notifying provider - record

A

Record all your actions

41
Q

Documentation - Never

A

Never use to describe a patient or patients behavior ex: obnoxious

42
Q

Correct documentation

A

Correct all errors promptly, using the correct method

43
Q

Record

A

Record all facts, do not enter personal opinions
If a order was questioned, record that clarification was sought

44
Q

Chart

A

Chart only for yourself and not for others

45
Q

Keep

A

Keep your computer password secure

46
Q

Avoid

A

Avoid generalizations

47
Q

Paper charting

A

Begin each entry with the date/time and end with your signature and title

48
Q

Correcting errors

A

A single line through entry and your initials
EMR- new entry , explain error
Make sure you have the right chart!!

49
Q

Late entry

A

Paper chart- add the entry to the first available line, and label it late entry to indicate that it’s out of sequence, according to facility policy
EMR- change date and time and then document

50
Q

Standards applicable to all nurses

A

Accurately and completely report and document
Client status including signs and symptoms
Nursing care rendered
Administration of medication and treatments
Clients responses
Contacts with other healthcare team members concerning significant events regarding clients status

51
Q

Records contain

A

Patient identification and demographic data
Informed consent for treatment and procedures
Admission data
Nursing diagnoses or problems
Care plans
Record of nursing care, treatment, and evaluation
Medical history
Medical diagnosis
Therapeutic orders
Progress notes
Physical assessment findings
Diagnostic study findings
Patient education
Summary of operations
Discharge plan and summary

52
Q

Purpose of records

A

Communication
Legal document
Reimbursement compliance
Education
Research
Auditing and monitoring
Continuing of care

53
Q

Documentation

A

Factual
Accurate
Complete
Current
Organized

54
Q

Subjective

A

Quotes from patient

55
Q

Anyone reviewing the chart must be able to understand an accurate, clear and comprehensive picture of

A

Patient’s needs
Nursing interventions
Patient outcome

56
Q

Documentation needs to be in

A

Chronological order
Clear
Concise
To the point
Complete sentence is not needed

57
Q

Documentation Donts

A

Don’t document a patient problem without charging what you did about it

Don’t alter patient’s record

Don’t write, imprecise descriptions, such as bed soaked

Don’t chart what someone else heard felt or smelled unless information is critical

Don’t chart ahead of time

58
Q

Paper charts

A

Print or cursive
Blue or black ink
Never use white out
Never erase

IM 1 (34 decks)

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