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KC'S CLASS > FON DOCUMENTATION > Flashcards

FON DOCUMENTATION Flashcards

1
Q

is the process of making an entry on a client record.

A

Documentation

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2
Q

any written or electronically generated information about a client that describes the status, care or services provided to that client.

A

Documentation

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3
Q

Record of nursing care that is planned and delivered to individual patients by nurses.

A

Documentation

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4
Q

A vital component of safe, ethical and effective nursing practice.

A

Documentation

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5
Q

According to _______ documentation requires client record to be timely, complete, accurate, confidential and specific to the client.

A

JCAHO

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6
Q

According to _____ the nurse has a duty to maintain confidentiality of all patient information.

A

ANA

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7
Q

According to _______ accurate documentation of actions and outcomes of delivered care is the hallmark of nusing accountability.

A

code of ethics for FIlipino Association

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8
Q

According to ________ thet maintain the privacy and confidentiality of 18 protected health information.

A

HIPAA

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9
Q

Purposes of Clients Record

A

-Communicatio
-Planning Client Care
-Auditing Health Agencies
-Research
-Education
-Reimbursement
-Legal Documentation
-Health Care Analysis

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10
Q

It is a purpose of clients records that prevents repetition, and delays in care

A

communication

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11
Q

It is a purpose of clients records where nurses use ongoing data to evaluate effectiveness of the care plan

A

Planning client Care

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12
Q

It is a purpose of clients records that review client record for quality assurance purposes

A

Auditing health agencies

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13
Q

It is a purpose of clients records where treatment plans for a number of client with same health problems can yield information.

A

Research

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14
Q

It is a purpose of clients records where students in health discipline often use client records as educational tools

A

Education

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15
Q

It is a purpose of clients records that helps facility receive reimbursement from federal government

A

Reimbursement

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16
Q

It is a purpose of clients records that is admissible in court as evidence

A

Legal Documentation

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17
Q

It is a purpose of clients records that assist health care planners to identify agency needs such as overutilized and underutilized hospital services

A

Health Care Analysis

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18
Q

MEASURES USE TO MAINTAIN THE CONFIDENTIALITY AND SECURITY OF COMPUTERIZED CLIENT RECORDS

A

-Confidientiality of all patient information.
-Client’s record protected legally as a private record of client’s care.
-HIPAA regulations updated on April 14, 2003
-Responsibility in using records for the purpose of education and research
-

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19
Q

The following are some suggestions for ensuring confidentiality and security of computerized records:

A

-A personal passwords is required to enter and sign off computer files. (in a month changes 3 times)
-Personal passwords should not be shared.
-Never leave the computer terminal unattended after logging on.
-Do not leave client information displayed on the monitor where others may see it.
-Shred all unneeded computer-generated worksheets. (10-20 years ago)
-Know the facility’s policy and procedure for correcting an entry error.
-Follow agency procedures for documenting sensitive material such as a diagnosis of AIDS.
-Information technology (IT) personnel must install a firewall to protect the server from unauthorized access.

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20
Q

DISCUSS THE DIFFERENT SYSTEM USED IN DOCUMENTING HEALTH CARE ACTIVITIES AND INTERVENTIONS

A

-Source-oriented record
-Problem-oriented medical records
-PIE
-Focus Charting
-Charting by exception
-Computerized records
-The case management model

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21
Q

Narrative Charting is what system?

A

Source - Oriented Record

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22
Q

Traditional Client Record

A

Source - Oriented Record

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23
Q

Information about a particular problem distributed throughout the record.

A

Source - Oriented Record

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24
Q

Convenient because care providers can easily locate the forms.

A

Source - Oriented Record

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25
Q

Consist of written notes that include routine care, normal finding, and client problems.
-There is no right and wrong order to the information, although chronologic order is frequently used.

A

Narrative Charting

26
Q

Data are arranged according to the client problem.

A

Problem - Oriented Medical Records

27
Q

Members of the health care team contribute to the problem list , plan of care, and progress notes

A

Problem - Oriented Medical Records

28
Q

Encourages collaboration and easier to track status of problems

A

Problem - Oriented Medical Records

29
Q

Disadvantages of problem-oriented medical records

A

-Caregivers differ in their ability to use the required charting format.
-Takes constan vigilance (watchfulness) to maintenance an up-to-date problem list.
-Somewhat inefficient because assessments and interventions that apply to more than one problem must be repeated.

30
Q

4 Basic Components of Problem - Oriented Medical Records

A

-Database
-Problem list
-Plan of care
-Progress notes

31
Q

All information known about the client where first enter agency.

A

Database

32
Q

Listed in order in which they are identified and others resolved.

A

Problem list

33
Q

Made with references to active problems.

A

Plan of Care

34
Q

Made by all health professionals involved in a client’s care.
Used SOAP, SOAPIE, SOAPIER Documentation

A

Progress Notes

35
Q

What is the meaning of the mnemonic SOAPIER

A

S-SD
O-OD
A-SSESSMENT
P-PLAN
I-NTERVENTON
E-VALUATION
R-EVISION/REASSESSMENT

36
Q

Ongoing client assessment flow sheet and progress notes.

A

PIE

37
Q

Focus on client concerns and strengths. ex: acute pain
Progress notes organized into DAR format

A

Focus Charting

38
Q

What does the mnemonic DAR means

A

Data - Assessment Phase
Action (intervention) “as per doctor’s order” - Planning and implementing phase
Response - Evaluation Phase

39
Q

Incorporation of:
-Flow sheets
-Standards of nursing care
-Bedside chart forms

A

Charting by exception

40
Q

Agencies develop standards of nursing practice

A

Charting by exception

41
Q

Documentation according to standards involves a check mark.

A

Charting by exception

42
Q

Exceptions to standards described in narrative form on nurse’s notes.

A

Charting by exception

43
Q

Developed to manage volume of information

A

Computerized Documentation

44
Q

Used by nurses to:
-Store client’s database, new data
-Create and revise care plans
-Document client’s progress
Information easy to retrieve

A

Computerized Documentation

45
Q

Speech-rate recognition technology
-Nurse must be alert and aware of others who might hear the dictation.

A

Computerized Documentation

46
Q

-Possible to transmit information from one care setting to another.
-Confidentiality is at risk

A

Computerized Documentation

47
Q

-Quality, cost-effective care delivered within established length of stay.
-Uses multidisciplinary approach, critical pathways, CBe

A

Case Management Model (patient na gumaling)

48
Q

A goal that is not met

A

Variance

49
Q

Documentation of variances include:

A

-Actions taken to correct the situation
-Justification of actions taken

50
Q

-Completed when client discharged
-Completed when client transferred to another institution

A

NURSING DISCHARGED/ REFERRAL SUMMARIES

51
Q

-Based on professional standards, federal and state regulations, policies of health care agency.

A

LONG-TERM CARE DOCUMENTATION

52
Q

Laws and Requirements of LONG-TERM CARE DOCUMENTATION

A

-Health care financing administration
-Omnibus Budget Reconcilation Act (OBRA) of 1987
-Medicare and Medicaid

53
Q

It is influenced by:
-Health Care Financing Administration (1985)
-Medicare and Medicaid
-Other third party payers

A

HOME CARE DOCUMENTATION

54
Q

Two records that are required in HOME CARE DOCUMENTATION

A

-Home health certification and plan-of-treatment form
-Medical update and patient information form

55
Q

Used to guide documentation practice

A

FACT

56
Q

Objective information about what an RN see, hears, feels, and smells

A

Factual

57
Q

the use of exact measurements and established accuracy.

A

Accurate

58
Q

charting must be complete, including appropriate and essential information.

A

Complete

59
Q

to reflect a clear record of what has happened

A

Timely

60
Q

What are the purposes of Records

A

-Communication
-Planning Client Care
-Auditing Health Agencies
-Research
-Education
-Reimbursement
-Legal Documentation
-Healthcare Analysis

61
Q

Documentation System

A

-the source-oriented record;
-the problem-oriented medical record;
-the problems, interventions, evaluation (PIE) model;
-focus charting;
-charting by exception (CBE);
-computerized documentation;
-case management.

62
Q

The POMR has four basic components:

A
  • Database
  • Problem list
  • Plan of care
  • Progress notes

KC'S CLASS (19 decks)

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