Documentation Power Point

Question 1

Nurses are _____ and ethically obligated to keep all patient information confidential.

Answer 1

legally

Question 2

Nurses are responsible for ______ records from all unauthorized readers.

Answer 2

protecting

Question 3

_____ requires that disclosure or requests regarding health information are limited to the minimum necessary.

Answer 3

HIPAA

Question 4

______ is anything written or printed as proof of patient actions and activities.

Answer 4

documentation

Question 5

The care provided as ______ or charting; it should reflect the nursing process.

Answer 5

documentation

Question 6

______ is a vital aspect of nursing practice.

Answer 6

documentation

Question 7

Information to document

Answer 7

Assessments
Medications
Treatments and responses
Client education

Question 8

Current documentation standards require that each _____ have an assessment that includes physical, psychosocial, environmental, self-care, patient education, knowledge level, and discharge planning needs

Answer 8

patient

Question 9

Nursing _____ standards are set by federal and state regulations, state statutes, standards of care, and accreditation agencies.

Answer 9

documentation

Question 10

_____ are when a professional caregiver giving formal advice to another caregiver

Answer 10

consultations

Question 11

____ are arrangement for services by another care provider.

Answer 11

referrals

Question 12

Interdisciplinary communication withing the health care team provides _______ among all team members who provided care to the same clients.

Answer 12

continuity of care

Question 13

Remember, if it wasn’t ______, it wasn’t done!!

Answer 13

documented

Question 14

Purposes of Records

Answer 14

communication
legal documentation
financial billing/reimbursement
client education
research
auditing/monitoring

Question 15

Legal Guidelines for Recording

Answer 15

Correct all errors promptly, using the correct method.
Record all facts; do not enter personal opinions.
Do not leave blank spaces in nurses’ notes.
Write legibly in permanent black ink.
If an order was questioned, record that clarification was sought.
Chart only for yourself, not for others.
Avoid generalizations.
Begin each entry with the date/time and end with your signature and title.
Keep your computer password secure.

Question 16

Guidelines for Quality Documentation and Reporting

Answer 16

Factual
Accurate
Complete
Current 
Organized
Nonjudgmental
Timely
Concise

Question 17

Common charting mistakes include failing to document _____ medications

Answer 17

discontinued

Question 18

Common charting mistakes include writing illegible or _____.

Answer 18

incomplete records

Question 19

Common charting mistakes include failing to record pertinent health & drug info, nursing actions,
that medications have been given, _____ or changes in client’s condition

Answer 19

drug reactions

Question 20

Methods of recording include a ___ record which is episode oriented, but key info ay be lost form one episode ot another.

Answer 20

paper

Question 21

Methods of recording include ____ which is a digital version of a patient’s medical record. It integrates all of a patient’s info in one record and improves continuity of care.

Answer 21

electronic health record (EHR)

Question 22

____ is the traditional method of recording.

Answer 22

narrative

Question 23

_____ is a method of recording that is a database that includes a problem list, care plan and progress notes.

Answer 23

problem oriented medical record (POMR)

Question 24

Methods of recording: progress notes include SOAP which stands for:

Answer 24

subjective
objective
assessment
plan

Question 25

Methods of recording: progress notes include SOAPIE which stands for:

Answer 25

``` subjective objective assessment plan intervention evaluation ```

Question 26

Methods of recording: progress notes include PIE which stands for:

Answer 26

problem intervention evaluation

Question 27

Methods of recording: progress notes include Focus Charting or (DAR) which stands for:

Answer 27

Data Action Response

Question 28

CBE in documentation stands for ___.

Answer 28

charting by exception

Question 29

____ are a separate section for each discipline to document.

Answer 29

source records

Question 30

CBE focuses on documenting ____.

Answer 30

deviations

Question 31

Case management plan and critical pathways incorporate a muldisciplinary approach to _____ and variances.

Answer 31

care

Question 32

_____ is a multidisciplinary approach to document client care

Answer 32

critical pathways

Question 33

Standardized plan of care is summarized into ____ with a case management plan.

Answer 33

pathways

Question 34

Critical pathways include a ____page integrated care plan for problems and includes key interventions and expected outcomes.

Answer 34

1-2

Question 35

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

Answer 35

admission nursing history form

Question 36

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

Answer 36

flow sheets and graphic records

Question 37

_____ is a A portable “flip-over” file or notebook with patient information

Answer 37

patient care summary or Kardex

Question 38

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

Answer 38

standardized care plans

Question 39

Common record keeping forms also include the ____ summary forms and acuity records.

Answer 39

discharge

Question 40

Forms that may be used by nurses

Answer 40

Progress notes Flow sheets D/C summaries Client education Kardexes MARs (Medication Administration Records)

Question 41

What to document?

Answer 41

``` Your interventions w/ patient’s response and your evaluation Any significant changes or events in condition Informed consent Patient teaching Any attempts to contact medical staff Patient leaving AMA Patient’s refusal of treatment Spiritual concerns Use of restraints Medication Administration ```

Question 42

Medicare has specific guidelines for establishing eligibility for _____.

Answer 42

home care

Question 43

_____ guidelines for establishing a patient’s home care cost reimbursement serve as the basis for documentation by home care nurses.

Answer 43

Medicare

Question 44

______ is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance.

Answer 44

Documentation

Question 45

Nurses need to document all their services for .

Answer 45

payment

Question 46

Governmental agencies are instrumental in determining standards and policies for ______.

Answer 46

documentation

Question 47

The ______ of 1987 includes Medicare and Medicaid legislation for long-term care documentation.

Answer 47

Omnibus Budget Reconciliation Act

Question 48

The department of health in states governs the _____ of written nursing records.

Answer 48

frequency

Question 49

Reporting Care

Answer 49

``` Change-of-shift Hands off care Telephone report to MD Transfer/Discharge reports Oral Written Computer-based ```

Question 50

A ____ report occurs with transfer of patient care and provides continuity and individualized care. Reports are quick and efficient.

Answer 50

hand-off

Question 51

_______ include Situation-background-assessment-recommendation (SBAR) and make sure to document every call and Read back the orders.

Answer 51

telephone reports and orders

Question 52

_______ are 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. Follow agency policy.

Answer 52

incident or occurrence reports

Question 53

_____ is a Report written about any event not consistent with routine operation of the HC unit or routine care of the client

Answer 53

incident/occurrence report

Question 54

An incident/occurrence report should be ______, accurate report exactly what is observed + F/U care given

Answer 54

Concise

Question 55

An incident/occurrence report is part of quality ______with the institution

Answer 55

improvement

Question 56

An incident/occurrence report investigates the occurrence/circumstances and may result in ____ that are needed to prevent recurrences

Answer 56

changes

Question 57

Critical Elements of an incident report

Answer 57

``` Date/time of occurrence How nurse found the client Witness info Assessment of client’s injury Actions taken + FU notations Who finds/witnesses the incident writes the report Not part of the medical record ```

Question 58

_____ is A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice

Answer 58

nursing informatics

Question 59

_____ is a group of systems used in a health care organization to support and enhance health care

Answer 59

Health Care Information System (HIS)

Question 60

_____ Consists of one or more Computerized clinical information systems (CISs) and/or Administrative information systems

Answer 60

nursing informatics

Question 61

Advantages of NISs

Answer 61

``` IIncreased time to spend with patients Better access to information Enhanced quality of documentation Reduced errors of omission Reduced hospital costs Increased nurse job satisfaction Compliance with accrediting agencies Common clinical database development ```

Question 62

Protection of the confidentiality of patients’ health information and the security of computer systems are ____ that include log-in processes, audit trails, firewalls, data recovery processes, and policies about handling and disposing of data to protect patient information.

Answer 62

top priorities

Question 63

You, and only you, should chart the care you give and _____ State’s Nursing Practices Acts prohibit having another chart for you on medical records.

Answer 63

supervise.

Question 64

____ of all malpractice suits are decided based on documentation (or lack thereof).

Answer 64

One fourth