documenting

Question 1

purposes of patient records

Answer 1

communication, diagnostic & therapeutic orders, care planning, legal, historical documentation, research, education, credentialing, reimbursement, quality improvement

Question 2

elements of documentation

Answer 2

avoid words “good” & “average” “pt is an angry old man”/ never document beef interventions are carried out/ never skip lines

Question 3

what is confidential

Answer 3

all info about pts written on paper, spoken aloud, saved on computer/ reason the person is sick/ treatment the pt receives/ info about past health conditions/ HIPAA

Question 4

what does HIPAA stand for

Answer 4

health insurance portability and accountability act

Question 5

potential breaches in pt confidentiality

Answer 5

displaying info on public screen/ sending confidential email messages via public info/ discarding copies of pt info in trash cans/ conversations in cafe, elevator, break room/ faxing info to unauthorized persons/ confidential messages over pagers

Question 6

when correcting an error, what do you do

Answer 6

draw single line through the error, above is write error and your initials

Question 7

last name and status when charting

Answer 7

T. Kurtz, KSU, SN

Question 8

what to chart

Answer 8

assessment at start of shift, changes in mental psychological physiological conditions, reactions to procedures or medications, teaching ( document what was taught and the clients response), physician visits, time client left and returned to unit, medications, treatments

Question 9

formats for nursing documentation: initial nursing assessment

Answer 9

baseline for later comparison

Question 10

formats for nursing documentation: care plan

Answer 10

communicate problems, goals, interventions

Question 11

formats for nursing documentation: patient care summary

Answer 11

overview of valuable pt data

Question 12

formats for nursing documentation:progress notes

Answer 12

info caregivers/ providers of progress pt is making / SOAP notes

Question 13

formats for nursing documentation: flow sheets and graphic records

Answer 13

flow sheets: quickly document aspects of patine care/ graphic record: form used to record specific variables such as vs, weight, I & O

Question 14

formats for nursing documentation: medication record (MAR)

Answer 14

must include all meds administered to the pt. also include nurse giving the drug, reason drug was ordered and its effectiveness

Question 15

formats for nursing documentation: discharge and transfer summary

Answer 15

summarize reason for tx, significant findings, procedures performed, tx rendered. the pts condition on D/C should also be recorded

Question 16

formats for nursing documentation: home healthcare/ long term documentation

Answer 16

ensure continuity of care. sent to third party payers, which establish need for continuing home health care as well as reimbursement for necessary services

Question 17

SOAP / SOAPIE

Answer 17

subjective, objective, assessment, plan/ documents one problem at time (implantation, evaluation)

Question 18

CBE

Answer 18

charting by exception/ document only abnormal or significant findings

Question 19

EHRs

Answer 19

computerized documentation/ electronic health records

Question 20

MAR

Answer 20

medication administration record

Question 21

incident is not

Answer 21

apart of the pts health record

Question 22

purposeful rounding, 4 P’s

Answer 22

potty, pain, position, and personal surroundings

Question 23

improvements from purposeful rounding

Answer 23

pt satisfaction scores, reduction in pt falls, reduction in call light use, decline in skin breakdown

Question 24

when recording a verbal order (VO) or telephone order (TO)

Answer 24

date and note the time orders were issued in emergency, followed by physicians name and nurses name and initials

Question 25

SBAR/ ISBARR

Answer 25

situation, background, assessment, recommendation/ identify or introduction, situation, background, assessment, recommendation, read back