Documentation & Reporting (Exam 2)

Question 1

What are the purposes of a patients medical record?

Answer 1

COMMUNICATION
continuity of care (communication among healthcare team)
legal record of care
reimbursement
quality improvement
accreditation
research
educational tool

Question 2

What is included in documenting regarding entering data about the patient?

Answer 2

assessment
intervention
nursing care
patient response to care

Question 3

Documentation must be…

Answer 3

OBJECTIVE AND PRECISE!! DOCUMENT EVERY 1-2 HRS

Avoid conjecture, best to describe what you see instead of assuming (“seems agitated”)
Avoid vague terms (“pain is better”, “good skin color”)
Be factual (who found the fallen pt?)
don’t use unapproved abbreviations

“no further concerns as of present”

Question 4

When documenting, you should be cautious with..

Answer 4

ABBREVIATIONS (HOSPITAL APPROVED LIST, JC DO NOT USE)

Question 5

What abbreviations are on the JC DO NOT USE list, and what should you use instead?

Answer 5

U/u unit
IU International unit
Q.D/QD/Q.O.D/QOD write daily or every other day
trailing 0/lack of leading 0. write X mg or 0.X mg
MS/MSO4/MgSO4 write morphine sulfate or magnesium sulfate

Question 6

How to correct errors when documenting

Answer 6

draw single line, no white out
write mistake entry with date and initials
CAN EDIT IN EMR, SYSTEM KEEPS RECORD

Question 7

When should you document?

Answer 7

admission
transfer
discharge
ongoing care per policy
change in condition
communication

Question 8

When can protected health information be released?

Answer 8

treatment
payment
normal healthcare operations

Question 9

Potential violations of HIPAA

Answer 9

discussing patients in public areas
leaving charts out
not logging off computers
copying forms
social media

Question 10

Verbal Orders

Answer 10

INCREASE RISK OF ERROR
VORB- Verbal Order Read Back
must be signed by prescriber ASAP

Question 11

Telephone Orders

Answer 11

READ BACK, SPELL UNFAMILIAR NAMES, PRONOUNCE DIGITS SEPARATELY
RECORD WITH DATE, TIME AND TORB-Telephone Order Read Back
must be co signed within 24 hours

Question 12

Source-Oriented Documentation

Answer 12

disciplines charted separately
data scattered, may lead to fragmentation

Question 13

Problem-Oriented Documentation

Answer 13

organized around clients problems and allows for greater collab

FOUR PARTS: DATABASE, PROBLEM LIST, PLAN OF CARE, PROGRESS NOTES

Question 14

Narrative Charting Documentation

Answer 14

use with source and problem systems
chronological story of care
tracks client changing status
can be lengthy and disorganized

Question 15

PIE Charting

Answer 15

Problem
Interventions
Evaluation

problem oriented, establishes ongoing plan of care

Question 16

SOAP(IER) Charting

Answer 16

Subjective Data
Objective Data
Assessment
Plan (short term and long term goals)
Intervention
Evaluation
Revision (of evaluation)

Question 17

Focus Charting

Answer 17

highlights clients concerns, problems or strengths in 3 columns

1: Time and date
2: Focus or problem being addressed
3: Charting in DAR format

Question 18

DAR Format

Answer 18

Data
Action
Response

Question 19

Charting by Exception

Answer 19

charting only significant findings or exception to norms
drop down boxes and checklists
OMISSIONS BIGGEST PROBLEM
do not just follow previous shift, assess what is normal in the moment

Question 20

FACT Documentation

Answer 20

Flow sheets (individualize specific services)
Assessment (baseline data)
Concise (progress notes)
Timely entries

Question 21

What are the advantages of EMR?

Answer 21

decreased error
more legible
improved access
quality control
cerner/EPIC

Question 22

Integrated Plans of Care (IPOC): Critical Pathways

Answer 22

based on EBP
specific group of patients with predictable clinical diagnosis
maps out from admission to discharge, interventions are defined

Question 23

What are the components of the record?

Answer 23

face sheet
graphics
flow sheet
progress notes
H+P
consults
operative report
orders
MAR
Lab
Diagnostics

Question 24

Nursing Admission Assessment

Answer 24

baseline data from which to monitor change; discharge planning information/needs

Question 25

Nursing Admission Database

Answer 25

chief complaint/reason for admission
physical assessment
vitals
allergies
current meds
ADLs
client support system and contact info

Question 26

KARDEX (Client Care Summary)

Answer 26

demographic data
medical diagnosis
allergies
diet/activity orders
safety precautions
IV therapy orders
ordered treatments
summary of meds ordered
isolation orders
DNR orders

Question 27

What are flow sheets?

Answer 27

record routine aspects of care (hygiene, turning)
document assessments by body systems
track client response to care
graphic records (vitals)
I&O record

Question 28

Should you reference incident/occurrence reports in your chart?

Answer 28

No!

Question 29

I-SBAR-R for reporting

Answer 29

Introduction
Situation
Background
Assessment
Recommendation
Read back

Question 30

CUBAN for reporting

Answer 30

Confidential
Uninterrupted
Brief
Accurate
Named nurse

Question 31

What are some methods for reporting?

Answer 31

face-to-face
walking rounds
telephone convos
messengers
written
audio-taped (not preferred)
computer messages

Question 32

What should be included in a transfer report?

Answer 32

your contact info
client demographics, diagnosis, reason for transfer
family contact info
summary of care
current status, including meds, treatments and tubes
prescence of wounds or open areas of skin
special directives (ex.isolation)
always ask if receiver has any questions!

Question 33

What to include in a discharge summary?

Answer 33

time of departure and method of transport
name and relation to accompanying persons
condition at discharge
teaching conducted and materials provided
discharge instructions (meds, activity, etc.)
follow up appointments or referrals
EHR