Documenting & Reporting Flashcards
Informal oral consideration of subject by 2 or more healthcare personnel to identify a problem or establish strategies to resolve a
problem.
ex. “Talking about the case of px”
DISCUSSION
Oral, written, or computer-based
communication to convey info to others.
- Ex: endorsement
REPORT
A legal document that provides evidence of a client’s care.
“Chart” or “Client-record”
RECORD
Process of making an entry on a client record
CHARTING / RECORDING
It maintains the privacy and
confidentiality of protected health
information (PHI)
HIPAA (Health Insurance Portability and Accountability Act of 1996):
Purposes of client record
- Communication
- Planning Client Care
- Auditing Health Agencies
- Research
- Education
- Reimbursement
- Legal Documentation
- Healthcare Analysis
- A vehicle (medium) for diff. health
professionals who interact w/ a client
communicate w/ e/o - Prevents fragmentation, repetition, and delays in client care
COMMUNICATION
- Nurses base on the record to formulate their
care plan - Doctors also make use of it to give treatment
plans/medicines
PLANNING CLIENT CARE
Health insurance companies or accrediting agencies may review client records to determine if the conditions are part of the coverage or meeting their standards
AUDITING HEALTH AGENCIES
The information contained in a record can be a valuable source of data for research. The treatment plans for a number of clients with the same health problems can yield information helpful in treating other clients.
RESEARCH
- Students in health disciplines (ex. Student Nurses) often use client records as educational tools.
- A record can frequently provide a
comprehensive view of the client, the illness, effective treatment strategies, and factors that affect the outcome of the illness.
EDUCATION
- Client’s record is a legal document that may be used in court as evidence.
- The client may object to use the record which makes it inadmissible as evidence
LEGAL DOCUMENTATION
Information from records may assist healthcare planners to identify agency needs, such as overutilized and underutilized hospital services.
Records can be used to establish the costs of various services and to identify those services that cost the agency money and those that generate revenue.
HEALTHCARE ANALYSIS
DOCUMENTATION SYSTEMS
- Source-oriented records
- Problem-oriented records
- PIE: Problems, Interventions, Evaluation
- Focus Charting
- Charting by Exception (CBE)
- Computerized Documentation
- Case Management
The traditional client record
SOURCE-ORIENTED RECORDS
Each healthcare provider or department makes notations
in a separate section or sections of the client’s chart. For example, the admissions department has an admission sheet; the primary care provider has a physician’s order
form, a physician’s history sheet, and progress notes; nurses use the nurse’s notes; and other departments or personnel have their own records.
SOURCE ORIENTED RECORD
In this type of record, information about a particular problem is distributed throughout the record.
SOURCE-ORIENTED RECORD
A very detailed charting and is a traditional part of the source-oriented record . Consists of written notes including both normal and abnormal findings, interventions,
assessment, effects of interventions, routine care
NARRATIVE CHARTING
➢ In this record, data is arranged according to client problem
(problem list)
➢ Healthcare team members contribute to problem list, care plans, and progress notes
➢ There is care plan and progress notes for each problem
PROBLEM-ORIENTED RECORD
– all Px info/hx upon admission
DATABASE
4 basic components of problem oriented record
DATABASE
PROBLEM LIST
PLAN OF CARE
PROGRESS NOTES
derived from database and
kept at the front of chart. Problems are listed in order in which they are identified and re continually updated. Includes physio, psycho, socio, cultural, spiritual, developmental, and environmental needs.
PROBLEM LIST
– initial list of orders or plan
of care in reference to the active
problems.
PLAN OF CARE
in the POMR is a chart entry made by all health professionals involved in a client’s care;
PROGRESS NOTES
➢ is intended to make the client and client concerns and strengths the focus of care.
➢ Uses DAR (Data, Action, Response) format
➢ Uses 3 column for recording:
- Date and Time,
- Focus: condition, nsg. dx, behavior, sign & symptom, acute change in cx condition
- Progress Notes: organized into DAR
FOCUS CHARTING
This system consists of a client care assessment flow sheet and progress
notes.
This system eliminates the traditional care plan and incorporates ongoing care plan into the progress notes
Each ___ is referred to by a number (ex. P#1, I#1, E#1) each specific to the problem.
PIE (PROBLEM, INTERVENTIONS, EVALUATION)
This system provides a holistic perspective of the client and the client’s needs. It also provides a
nursing process framework for the progress notes (DAR).
FOCUS CHARTING
3 Key Elements of Charting by Exception
- FLOW SHEETS
- STANDARDS OF NURSING CARE
- BEDSIDE ACCESS TO CHART FORMS
Is a documentation system in
which only abnormal or significant findings or exceptions to norms are recorded.
CHARTING BY EXCEPTION (CBE)
Case Management Model:
It is a deviation from
what was planned on the critical pathway—unexpected
occurrences that affect the planned care or the client’s
responses to care
VARIANCE
➢ Emphasizes quality, cost-effective care delivered
within an established length of stay.
➢ Uses multidisciplinary approach to planning
and documenting client care, using critical
pathways
CASE MANAGEMENT MODEL
If goals are NOT met in a case management model, then it is called a ______
VARIANCE
➢Use of electronic health records (EHR)
➢ Taking advantage of technology by using
computers / tablets / iPads to document data or
chart.
➢ Allows easy transfer of information from one
place to another (ex. From hospital to primary
doctor or referral hospital)
➢ Systematic and organized
COMPUTERIZED DOCUMENTATION
➢ Comprehensive admission assessment
➢ Also referred to as an initial database, nursing history, or nursing assessment, is completed when the client is admitted to the nursing unit.
ADMISSION NURSING ASSESSMENT
Types of Flow Sheets
- GRAPHIC RECORDS
- INTAKE & OUTPUT
- MEDICATION ADMINISTRATION RECORD
- SKIN ASSESSMENT RECORD
2 TYPES OF NURSING CARE PLANS
- TRADITIONAL CARE PLAND
- STANDARD CARE PLANS
A care plan written for each client. Varies according to client needs
TRADITIONAL CARE PLAN
A care plan developed to save documentation time and is based on institutional standards of practice. It must be individualized.
STANDARD CARE PLAN
➢ Concise method of organizing & recording data
➢ Consists of series of cards kept in portable index file or comp-gen forms
KARDEX
It enables nurses to record nursing data quickly and concisely and provides an easy-to-read record of the client’s condition over time
FLOW SHEETS
This record typically indicates body temperature, pulse,
respiratory rate, blood pressure, weight, and, in some
agencies, other significant clinical data such as admission
or postoperative day, bowel movements, appetite, and
activity.
GRAPHIC RECORD
All routes of fluid intake and all routes of fluid loss or output are measured and recorded on this form
INTAKE & OUTPUT RECORD
It includes date of med orders, expiration date, med name and dose, frequency of administration, route, nurse signature
MEDICATION ADMINISTRATION RECORD
It is made by nurses that provide information about the progress a client is making toward achieving desired outcomes
PROGRESS NOTES
Long term care documentation that require more extensive nursing care
SKILLED CARE
These are completed when the client is being discharged and transferred to another institution or to a home setting where a visit by
a community health nurse is required.
NURSING DISCHARGE & REFERRAL SUMMARIES
Long term care documentation For clients who usually have chronic illnesses and may only need
assistance with ADL
INTERMEDIATE CARE
GENERAL GUIDELINES FOR RECORDING
- DATE & TIME
- TIMING
- LEGIBILITY
- PERMANENCE
Two records required by the U.S. Department of Health and Human Services when it comes to home care documentation
A. HOME HEALTH CERTIFICATION
B. MEDICAL UPDATE & CLIENT INFROMATION FORM
Document the date and time of each recording. This is essential not only for legal reasons but also for client
safety. Record the time in the conventional manner
DATE & TIME
Follow the agency’s policy about the frequency of documenting, and adjust the frequency as a client’s condition
indicates
TIMING
All entries must be legible and easy to read to prevent
interpretation errors.
LEGIBILITY
All entries on the client’s record are made in dark ink
PERMANENCE
ac
“ante cebum”
BEFORE MEALS
ad lib
AS DESIRED
ADL
ACTIVITIES OF DAILY LIVING
bid
TWICE DAILY
BRP
BATHROOM PRIVILEGES
DAT
DIET AS TOLERATED
c̅
WITH
gtts
DROPS
h
HOUR
The purpose of this is to communicate specific
information to an individual or group of people
REPORTING
NPO
NOTHING PER OREM
Is essential for accuracy in recording
CORRECT SPELLING
Also called as “Handoff Communication”
CHANGE-OF-SHIFT REPORTS
Are procedures in which two or more
nurses visit selected clients at each client’s bedside to:
* Obtain information that will help plan nursing care.
* Provide clients the opportunity to discuss their care
NURSING ROUNDS
- Document the time & date, name of
the indiv. giving info and suject of info
received. State that it is a telephone
order (T.O.) - The individual receiving the
information should repeat it back to
the sender for accuracy
TELEPHONE REPORTS
Defined as a process in which information about client care is communicated
HANDOFF COMMUNICATION
- Which action by a nurse ensures confidentiality of a client’s computer record?
- The nurse logs on to the client’s file and leaves the computer
to answer the client’s call light. - The nurse shares her computer password.
- The nurse closes a client’s computer file and logs off.
- The nurse leaves client computer worksheets at the computer workstation
3
- Meeting of group of nurses to
discuss possible sol’ns to certain
problems of a client - Allows nurses & other professionals
to offer an opinion
CARE PLAN CONFERENCE
Write the complete order down and
read it back to the primary care
provider
TELEPHONE & VERBAL ORDERS
- A client states: “I really don’t want anyone who has not been
cleared by me first to visit me.” If utilizing the SOAP format, this
statement would be documented under which category? - Subjective data
- Objective data
- Assessment
- Planning
1
- The client’s VS are WNL. He has BRP and he receives his
pain pill prn. His nutrition is DAT. Interpret the commonly used
abbreviations. - WNL: __________________
- BRP: __________________
- prn: __________________
- DAT: __________________
1
- Which charting entry would be the most defensible in court?
- Client fell out of bed
- Client drunk on admission
- Large bruise on left thigh
- Notified Dr. Jones of BP of 90/40
4
- A student nurse observes the change-of-shift report. Which
behavior(s) by the reporting nurse represents effective nursing
practice? Select all that apply. - Provides the medical diagnosis or reason for admission.
- States the time the client last received pain medication.
- Speaks loudly when giving report.
- States priorities of care that are due shortly after the report.
- Reports on number of visitors for each client.
1,3,4
- During the first day a nurse is caring for a client who has been
in the hospital for 2 days, the nurse thinks that the client’s blood
pressure seems high. What is the next step? - Ask the client about past blood pressure ranges.
- Review the graphic record on the client’s record.
- Examine the medication record for antihypertensive
medications. - Review the progress notes included in the client’s record.
2
- After completing client care and documenting it in the progress
notes, the nursing student discovered he had written in the
wrong chart. What is the correct action? - Use white-out over the mistake.
- Take a wide permanent marker and blacken out all the
documentation. - Put an “X” through the entire page, identify it as an “error,”
initial, and move on to the correct chart. - Draw a single line through the documentation, write
“mistaken entry” next to the original entry, and initial it.
4
- Which charting rule(s) will keep the nurse legally safe? Select all
that apply. - Use military time.
- Document worries or concerns expressed by the client.
- Perform most of the charting at the end of the shift.
- Record only information that pertains to the client’s health
problems
3
- Which charting entries are written correctly? Select all that apply.
- MS 5 gr given IV for c/o abdominal pain
- Lanoxin 0.25 mg given orally per Dr. Smith’s stat order
- KCl 15 mL given orally for K+ level of 2.9
- Regular insulin 10.0 u given SQ for capillary blood glucose
of 180 - Ambien 5 mg given orally at bedtime per request
1
- A nurse responds to a client’s call light. On entering the room,
the nurse sees that the client is lying on the floor, with the bed
linens around the legs. What is the most correctly written chart
entry? - Client fell out of bed but did push the call button for
assistance. - Client became tangled in the bed linens, then called for
assistance after falling out of bed. - Recorder responded to client’s call light, upon entering the
room, found client on floor. - Client found on floor, appeared to have fallen out of bed as a
result of getting tangled in bed linens.
4
