EXAM 3- Documentation Flashcards
what should you accurately & completely document routinely as a nurse?
- pt status - including s/s
- nursing care
- medication & treatment administration
- pt response to interventions
- any contact with health care team members concerning significant events (CN, provider, PT, RT, chaplain, etc)
what’s the difference between signs & symptoms?
- signs- objective, observable
- symptoms- subjective (what the pt tells you)
examples of treatments as nursing interventions
- nursing care
- ambulation
- TCDB
- wounds care
ANA standards for documentation
- relevant data- accurately & accessible to the team
- problems & issues- facilitates determination of the expected outcomes/plan
- expected outcomes- measurable goals (decrease pain level from an 8 to a 3)
- plan uses standard language/ terms
- implementation & modifications- including changes of the plan (put the plan into action)
- coordination of care
- results/evaluation
- quality & performance improvement- involved in nursing practice
what do formal pt records contain?
- pt identification & demographic data, medication hx
- admission data, discharge plan
- informed consent, pt education, summary of operations
- nursing diagnoses/ problems, care plans, treatment & evaluation, physical assessment
- medical diagnosis, therapeutic orders, diagnostic study
- progress notes
what are some purposes of pt records?
- communication
- legal document
- reimbursement compliance
- educaiton/ research
- auditing/ monitoring
is the pt chart a persuasive witness/ read as a legal document?
yes
it is a description of the facts at the time
why are charts important for communication?
allows for continutity & risk reduction between multi-disciplinary teams
nursing, medicine, PT, etc
components of proper documentation
5
- factual
- accurate
- complete
- current
- organized
how can you keep your documentation factual?
- objective
- descriptive
- subjective (quotes) from pt or family
just the facts
you heard a thud and went to the room & found pt on the floor. what should you document?
A. RN heard a thud and found the pt lying on the floor. it appears the pt has fallen while getting out of bed
B. pt fell in room, event was not observed by staff
C. RN heard a thud, went to the room & found pt lying on floor in room
D. RN found pt on floor and assumes the pt’s family member neglected to help them up
C
always document exacly what happened, NEVER ASSUME
how can you document accurately?
- use exact measurements
- clear
- understandable
- standard abbreviations only
- time, date, signature, title
- spelling
how can you document completely?
- condition change (onset, duration, location (PQRST), description, precipitating factors, behaviors)
- do not leave blanks (use N/A or lines)
- communication with pt & family (document the ed. you gave, as well as their repsonse (agreement/disagreement))
what should the chart ultimately reveal?
- pt needs
- nurse’s interventions
- pt outcome
how can you keep your documenting current?
- chart as soon as possible/ at the time of occurrence
- use military time
- never pre-chart (illegal falsiication)
how can you keep your documenting organized?
- chronological order
- concise, clear, to the point
- complete sentences not needed
terms to avoid in charting
accidentally apparently appears assume confusing could be may be miscalculated mistake somehow unintentionally normal good bad
fix the error:
pt has normal lung sounds
lung sounds clear bilaterally
avoid using the word “normal”, be desrcriptive
true or false
you can document a pt problem as long as you plan on charting your intervention later on
don’t document a pt problem w/o charting what you did about it
false
true or false
altering a pt record is a crime
true
true or false
you should avoid writing imprecise descriptions (bed soaked, large amount, etc)
true
true or false
you can document what someone else heard, felt, or smelled if they tell you the exact information of the occurrence
don’t chart what someone else heard, felt, or smelled unless the information is critical
use quotations appropriately
false
narrative documentation
- written in order of pt exerience
- provides details of pt care, status, activies, nursing interventions, psychosocial context, & response to treatment
- charting by exception
PIE
- Problem
- I-ntervention
- Evaluation
nursing focused (rather than medical focused) and eliminates need for separate care plan
SOAP/SOAPIE/SOAPIER
- S- subjective data
- O- objective data
- A- assessment
- P- plan
- I- intervention
- E- evaluation
- R- revision
DAR
- Data
- Action
- Response
what types of forms would be on a flow sheet?
- vital signs
- assessment check list
- I/O
medication administration records (MAR)
- scheduled meds
- unscheduled meds
- drug allergies
- single order meds
kardex
summary of pt needs & care
- pt data (name, age, marital status, religion, physician, family contact
- medical diagnoses listed by priority
- allergies
- medical orders
- activities permitted
NOT. a part of permanent record
what should you use to write a paper chart?
- blue or black ink
- no white out/ erasable pens
is the kardex a part of the permanent record?
no
SBAR
- Situation
- Background
- Assessment
- Recommendation
what do nurse’s notes contain?
- pt condition, problems, & complains
- interventions
- pt response to interventions
- achievement of outcomes
- additional assessment
- report given/received (nurse’s name, time, important information)
should you document when you give/ receive report?
YES!!
include the nurse’s name, time, any important information
components of good documentation
- who
- what (assessment findings, cc, care provided)
- when (when you provided care)
- where (where did the event/tx take place)
- how (how was tx completed, how did pt respond/tolerate)
- outcome (outcome of procedure, tx)
- follow-up (what f/u is needed, vitals, pain level, etc)
- accuracy (exact measurements)
- objective vs subjective data
what should you document when notifying a provider?
- full name of provider
- exact time of notification
- specific lab result, symptom, or assessment data
- provider’s response
- any orders the provider gives
- vitals, observations, nursing interventions
- f/u by provider
- symptoms & parameters
- note your own actions to assist pt
- pursue chain of command if provider doesn’t answer
- record all your actions
what should you include when documenting a pt’s refusal?
document:
* pt refusal
* reason for refusal
* what you did about it
true or false
you should NEVER use labels to describe a pt or their behavior
true
be more desrciptive
wound is infected
- skin around wound is red
- warm to touch
- purulent disharge
- pt complains of increased paid x1 day
be more descriptive
pt is nervous
pt asked several times about length of hospitalization, discomfort, and time off work
what should you document if you question a provider’s order?
document that clarification was sought
how do you correct an error on a paper chart? on EMR?
- single line through entry, write your initials
- EMR: make a new entry, explain the error
how should you chart a late entry in a paper chart? EMR?
- paper: add entry and title “late entry”, record the date/time of the entry & the date/time it should have been made
- EMR: change date/time & document (this can be tracked/audited)
be more descriptive
1900 pt arrived to ER complaining of stomach pain
include PQRST to describe pain more accurately
what % of the most frequent allegations against nurses in medical liability claims deal with documentation?
66%
why do nurses commonly have claims made against them concerning documentation?
- ascence of documentation- if it wasnt charted, it wasnt done
- timing of documentation- (late entries) self servind, different that what would ahve been charted at the time of tx
