Documenting and Reporting

Question 1

what is documentation

Answer 1

The act of recording client assessments and care in written or electronic form
Creating a record of client assessments and care

Question 2

what is the purpose of the written record

Answer 2

Communication between providers
Educational tool
Legal documentation of care
Quality improvement
Research
Reimbursement
Education

Question 3

what is source-oriented documentation

Answer 3

Disciplines charted separately

Variety of sections (e.g., admission, H&P, diagnostic, graphic, nurses’ notes, progress notes, lab, rehab, DC plan, etc.)

Data scattered; may lead to fragmentation

Question 4

what is problem-oriented documentation

Answer 4

Organized around client problems
Four components: database, problem list, plan of care, and progress notes
Allows greater collaboration

Question 5

what is common types of charting

Answer 5

Narrative
 PIE
 SOAPIER
Charting by Exception (CBE)
  Electronic entry format

Question 6

what is narrative charting

Answer 6

Can use with source- or problem-oriented system
“Story” of care in chronological format
Tracks the client’s changing status
Can be lengthy and disorganized

Question 7

what is PIE charting

Answer 7

Problem
Interventions
Evaluation

Used only in problem-oriented charting
Establishes an ongoing plan of care

Question 8

what is SOAP charting

Answer 8

Subjective data
Objective data
Assessment
Plan

Some Add IER
Intervention
Evaluation
Revision

Question 9

what is charting by exception

Answer 9

Chart only significant findings or exceptions to norms
Streamlines charting and saves time
Uses preprinted forms and checklists
Inadvertent omissions are biggest problem

Question 10

what is electronic health records

Answer 10

Many different types due to differences in software
Can be cumbersome to learn all entry methods and pathways
Often can be accessed from MD office and shared between departments

Question 11

what is a nursing admission assessment

Answer 11

Record of baseline data from which to monitor change

Helps forecast future needs

Question 12

what is included in the admission database

Answer 12

Chief complaint or reason for admission
Physical assessment data
Vital signs
Allergy information
Current medications
ADL status and discharge planning information/ needs
Data about client support system and contact information

Question 13

what are flow sheets

Answer 13

Record routine aspects of care (hygiene, turning)
Document assessments; usually organized according to body systems
Track client response to care (wound care, pain, intravenous fluids)
Graphic records - used to record vital signs
Intake and output record

Question 14

what are MARS…Medication administration records

Answer 14

Comprehensive list of all ordered medications
Provides information on client’s medication allergies
Documents scheduled/routine, PRN, STAT, or omitted doses
Additional explanation may be required for nonroutine or omitted medications

Question 15

what is in a KARDEX or client care summary

Answer 15

Demographic data
Ordered treatments (wound care, physical therapy), surgery, laboratory, and tests
A summary of medications ordered
Medical diagnoses
Allergies
Diet/activity orders 
Safety precautions
Intravenous therapy orders

Question 16

what is reporting

Answer 16

Informing other caregivers about the client condition
Nurse to nurse; nurse to physician

Passage of vital information related to the client’s status/plan of care

Question 17

what are occurrence reports

Answer 17

Formal record of unusual occurrence or accident
Not a part of patient’s health record
Quality improvement

Question 18

what is included in Hand-off report

Answer 18

Verbal, Through walking rounds, Audio-recorded report (not the preferred method)
Client demographics and diagnoses
Relevant medical history
Significant assessment findings
Treatments (e.g., wound care, breathing treatments)
Upcoming diagnostics or procedures
Restrictions (e.g., diet, activity, isolation)
Plan of care for the client
Concerns

Question 19

what are in transfer reports

Answer 19

Your contact information
Client demographics, diagnoses, reason for transfer
Family contact information
Summary of care
Current status, including medications, treatments, and tubes in the client
Presence of wounds or open areas of the skin
Special directives, code status, preferred intensity of care, or isolation required
Always ask if the receiver has any questions

Question 20

what is in a discharge summary

Answer 20

Time of departure and method of transportation
Name and relationship of person(s) accompanying client at discharge
Condition of client at discharge
Teaching conducted and handouts/informational matter provided to client
Discharge instructions (including medications, treatments, or activity)
Follow-up appointments or referrals given

Question 21

how do you document client care

Answer 21

Be familiar with facility forms
Chart in the required format
Include all aspects of care
Be accurate, complete, and consistent

Question 22

Long term care documentation

Answer 22

Minimum data set (MDS) for resident assessment and care screening must be completed within 4 days of admission and updated every 3 months

Question 23

what is a long-term care weekly summary

Answer 23

A summary of the client’s condition
An evaluation of the client’s ability to perform ADLs
The client’s level of orientation and mood
Hydration and nutrition status
Response to medications
Any treatments provided
Safety measures used (e.g., bed rails)

Question 24

Documentation Do’s and Dont’s

Answer 24

Be accurate and nonjudgmental
Adhere to the requirements for reimbursement
Provide details about the client’s condition, nursing interventions provided, and client response
Document legibly and as soon as possible

Question 25

what are some more documentation Do’s & Dont’s

Answer 25

Record significant events or changes in condition
Record any attempts you have made to contact the primary care provider
Chart teaching performed
Chart use of restraints, including reason for use, type of restraints, and frequent checks of the client

Question 26

Documentation Do’s and Dont’s

Answer 26

Do not chart that you have filled out an occurrence report
Chart any client refusal of treatment or medication
Document any spiritual concerns expressed by the client and your interventions

Question 27

Documentations Do & Dont’s

Answer 27

Always use black or blue ink for handwritten notes
Date, time, and sign all notes
Avoid subjective terms 
Use proper spelling and grammar
Use only authorized abbreviations
Document complete data about medications

Question 28

what to Document if a client refuses medication

Answer 28

Record on the medication administration record in narrative form; chart the reason given
Do not leave blank lines
If you make a mistake, draw a single line through the entry and place your initials next to the change
Sign all your charting entries