Documentation- Exam 3 Flashcards
Relevant data
Accurately and in a manner accessible to the interprofessional team
Problems and issues
In a manner that facilitates the determination of the expected outcomes and plan
Expected outcomes as..
Measurable goals
Discharge happens when
On admission
Purpose of records
Communication
Legal document
Reimbursement compliance
Education
Research
Auditing and monitoring
Continuity of care
Communication
Critical for continuity and risk reduction
- current status/ needs
- progress
- therapies
- consultations
- education
- discharge planning
Documentation needs to be
Factual
Accurate
Complete
Current
Organized
You need to be what on documentation
Objective
Descriptive
Subjective (quotes)
NO ASSUMPTIONS
Anyone reviewing the chart must be able to understand an accurate, clear and comprehensive picture of
Patient needs
Nurses interventions
Patient outcome
When to document
As soon as possible
Time or occurrence
Never pre-time
Documentation needs to be in
Chronological order
Clear
Concise
To the point
Complete sentences not needed
Avoid these terms
Accidentally
Apparently
Appears
Assume
Confusing
Could be
May be
Miscalculated
Mistake
Somehow
Unintentionally
Normal
Good
Bad
Documentation don’ts
-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
Narrative
Written in order of patient experience happens
Provides details in patients care, status, activities, nursing interventions, psychological context and response to treatment
Problem-intervention-evaluation (PIE)
Nursing focused instead of medical focused and elongated need to separate care plan
Soap/soapie/soapier
Subjective data, objective data, assessment, plan, intervention, evaluation, revision
DAR
Data, action, response
Flow sheets
Check list - assessment
Vital signs
Intake and output
Medication administration record
Scheduled meds
Unscheduled meds
Drug allergies
Single order medications
Kardex
Not a permanent record
A summary of pts needs and care
Paper charts
Print or cursive
Blue or black ink
Never use white out
Never use erasable ink
Never obliterate
Never erase - no pencils
SBAR
Situation
Background
Assessment
Recommendation
Nurses progress
Notes / narrative
Patients condition, problems, and complaints
Interventions
Patients response to interventions
Achievement of outcomes
Additional assessment
Report given
Time
Nurses name
Important information
Components of good documentation
Who, what, when, where, how, outcome
Who
The patient
What
Assessment findings
Patients condition
Care you provided
When
The time when you provided care
Where
Where did event take place
Where was the treatment given or medication administered
How
How was treatment completed
How did the resident tolerate the procedure/ treatment
Outcome
Outcome of the procedure / treatment
Follow up
What type of follow up needed
Accuracy
Exact measurement
Specific aspects of care
Fall reduction
Infection prevention
Non-conforming and management
Pain assessment and management
Restraints
Skin care
Suicide
Notifying provider
Include
Include the full name of the provider
Notifying provider - note
Note the exact time that you notified provider
Notifying provider -state
State the specific laboratory result, symptom, or other assessment data that you reported
Notifying provider - record
Record the providers response, using exact words if possible
Notifying provider- include
Any order the provider gives or when they don’t give orders
Notifying provider- pursue
If a provider fails to respond to a page, a telephone message, or fails to order an intervention
Notifying provider - record
Record all your actions
Documentation - Never
Never use to describe a patient or patients behavior ex: obnoxious
Correct documentation
Correct all errors promptly, using the correct method
Record
Record all facts, do not enter personal opinions
If a order was questioned, record that clarification was sought
Chart
Chart only for yourself and not for others
Keep
Keep your computer password secure
Avoid
Avoid generalizations
Paper charting
Begin each entry with the date/time and end with your signature and title
Correcting errors
A single line through entry and your initials
EMR- new entry , explain error
Make sure you have the right chart!!
Late entry
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
Standards applicable to all nurses
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
Records contain
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
Purpose of records
Communication
Legal document
Reimbursement compliance
Education
Research
Auditing and monitoring
Continuing of care
Documentation
Factual
Accurate
Complete
Current
Organized
Subjective
Quotes from patient
Anyone reviewing the chart must be able to understand an accurate, clear and comprehensive picture of
Patient’s needs
Nursing interventions
Patient outcome
Documentation needs to be in
Chronological order
Clear
Concise
To the point
Complete sentence is not needed
Documentation Donts
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
Paper charts
Print or cursive
Blue or black ink
Never use white out
Never erase
