Documentation part 1 Flashcards
What is documentation?
any written or electronically generated information about a client that describes the care or service provided to that client
What are the 6 purposes of pt. records?
COMMUNICATION & CARE PLANNING
LEGAL DOCCUMENTATION
EDUCATION
FUNDING & RESOURCE MANAGEMENT
RESEARCH
QUALITY REVIEW
How does documentation improve communication and care planning?
- All health care members communicate pt needs, progress, care, tx, and education
- ensures consistency and continuity of care
- provides baseline data
What does documentation do in terms of the benefit of being a legal document?
- demonstrates accountability
- best defense against legal claims
- care not documented is care not given
- need to document assessments, care, pt. responses, instructions, referrals
What is the purpose of documentation in terms of education?
- nurses/students can learn about illness and patterns of behaviour
- enables student to see patterns and types of care provided/needed
- helps to understand the uniqueness of each pt.
What is the purpose of documentation in terms of funding and resource management?
- shows how HC resources have been used
- level of acuity of pt indicates the type and of resources required
What is the purpose of documentation in terms of research?
- provides data for statistical purposes
- analysis of data for research purposes
what is the purpose of documentation in terms of quality review?
- evaluation of the quality and appropriateness of care
- audit chart after discharge or while pt is in hospital
- allows other disciplines to work together
- deficiencies are shared and results in change of practice/policies
what are the 6 guidelines for quality documentation?
1) Factual information
2) Accurate
3) Complete
4) Current
5) Organized
6) complies with standards
What should you ensure your documentation is like to be factual?
descriptive, objective
non-judgmental
no inferences without supporting data
avoid: appears, seems, apparently
Subjective data needs to have quotations and be as exact as possible
What should you ensure your documentation is like to be accurate?
accurate and specific time, amount, size, description, response
spelling
initials/signature and status after each timed charting entry
if there is an error, signal line through it, above “charting error” and initials
“Late entry” addendum to note of Jan. 13/12
any blank spaces need to have a line through them
What does telegraphic mean?
certain words may be omitted to allow quick and rapid transmission
What are some abbreviations to avoid?
U, IU, abbreviated drug names, @
QD or OD use daily
QOD use every other day
OS, OD, OU write it out
D/C use discharge
< and > use words
NEVER use 0 by itself after a decimal
ALWAYS use 0 before a decimal (0.5 not .5)
How can you ensure your documentation is complete?
make sure it includes all of the pt’s status, care given and response to care
ensure appropriateness
What does it mean to have current documentation?
timely entries
make sure data is recorded at time of occurrence (never before hand) ex med admin, tx’s, prep for tests/surgery, change in status, admission, death
What factors contribute to the frequency of documentation needed?
Acuity
Complexity
Variability
these all inc the freq
What are some of the standards documentation must meet?
each pg has pt. name and ID #
date of data entry on each page, include new date if it changes
include a time with ever newly timed entry
signature/initials and status of recorder with every timed entry
What is documentation by inclusion?
done by ongoing/regular basis
makes note of all assessment findings, interventions and client outcomes
What is documentation by exception?
Notes only the negative findings that vary from the norm.
Requires the facility to have detailed policies defining the norm
What is narrative charting?
most traditional
includes care given, observations, pt responses
is in chronological/care format
What are the disadvantages of narrative charting?
lengthy and cluttered
little structure if no documentation guidelines
information becomes scattered throughout the chart
time consuming
What does the acronym SOAP or SOAPIER stand for related to charting
S ubjective data O bjective data A sessments P lan I mplementation E valuation R evision
What is the SOAP or SOAPIER type of charting?
type of problem oriented charting
charting is relation to specific patient problems
POMR/ADIE are variations of this
What are the disadvantages for SOAP or SOAPIER charting
some overlaps
hard to get all disciplines using the same format
What is focus charting?
It is a column format for charting
pt. concern identified/key words identified (ex pain, agitation)
includes subjective and objective data
TWO TYPES DARE AND DARP
What does DARE stand for?
it is used in focused charting
D ata
A ction (present/future)
R esponse
E xpected outcome(s)
expected outcomes ex pt will have a temperature of 37C by 1800 hrs
What deos Darp stand for?
Used for focused charting
D ata
A ction (present)
R esponse
P lan (future actions)
plan ex assess TPR q 4h for 24 hours
What are the advantages of focus charting?
dec charting time
patient centered notes
inc usefulness in a clinical setting
problem identified/resolution clearly documented
What is the disadvantage of focus charting?
it is easy to switch to narrative charting due to fitting information in under appropriate sections
What is charting by exemption (CBE)?
chart only exception to the rule (significant/abnormal data)
several components to this system
- flow sheets
- standards of practice
- standard care plans
What is the advantage of charting by exemption?
forms kept at pt’s bedside therefore no need for transcription and therefore time saving
What is the disadvantage of charting by exemption?
Staff education/accountability
need to be intimately familiar with the defined policies to understand what should and should not be charted
What are some examples of permanent documentation tools?
flow sheets
fluid balance records
checklists
What are some advantages of documentation by permanent documentation tools
helps with routine care
time saver
ensures systematic assessment
is comprehensive (greatest amount of info in one area)
What is the disadvantage of documenting by permanent documentation tools?
some duplication possible
What are care maps/care paths?
maybe multidisciplinary
standardized plan for care
has expected outcomes with time frame
uses several components:
- focus charting for variance
- sample signature sheet
What are the advantages of care maps/care paths?
reduces duplication and amount of charting
reduces amount of time charting
What is the disadvantage of care maps/care paths?
only includes variations for specific health issues/situations
