fundamentals- chapter 7 Flashcards
1
Q
purposes of documentation
A
- provides a written record of the history, treatment, care, and response of the patient while under the care of a health care provider
- a guide for reimbursement of costs of care
- may serve as evidence of care in a court of law
- shows the use of the nursing process
- provides data for quality assurance studies
2
Q
purposes of documentation
A
- is a legal record that can be used as evidence of events that occurred or treatments given
- contains observations by the nurse’s about the patient’s condition, care, and treatment delivered
- shows progress toward expected outcomes
3
Q
documentation and the nursing process
A
- Written nursing care plan or interdisciplinary care plan is framework for documentation
- charting organized by nursing diagnosis or problem
- Implementation of each intervention documented on flow sheet or in nursing notes
- Evaluation statements placed in nurse’s notes and indicate progress toward the stated expected outcomes and goals
4
Q
the medical record
A
- Contains data about patient’s stay in a facility
- Only health care professionals directly caring for the patient, or those involved in research or
teaching, should have access to the chart - Patient information should not be discussed with anyone not directly involved in the patient’s care
5
Q
methods of documentation
A
- source-oriented (narrative) charting
- problem oriented medical record (POMR) charting
- focus charting
- charting by exception
- computer-assisted charting
- case management system charting
6
Q
source oriented (narrative) charting
A
- organization according to source if information
- separate forms for nurses, physicians, dietitians, and other health care professionals
- requires documentation of patient care in chronologic order
- Head-to-Toe assessment
- charts normals and abnormals
- lengthy and descriptive
- includes safety information
7
Q
problem-oriented medical record (POMR) charting
A
- focuses on patient status rather than on medical or nursing care
- five basic parts:
1. database
2. problem list
3. plan
4. progress notes
5. discharge summary - documents care by focusing on patient problems
- promotes problem-solving
- keeps relevant data in one place
- allows easy auditing
- not chronological
- fragments data
8
Q
focus charting
A
data, action, response (DAR)
- shortens charting time
- patient problems may be missed is database is insufficient
9
Q
charting by exception
A
- based on the assumption that all standards of practice are carried out and met with a normal or expected response unless otherwise documented
- a longhand note is written only when the standardized statement on the form is not met
- highlights abnormal data
- decreases charting time
- can lead to not charting enough
10
Q
computer-assisted charting
A
EHR
- computerized record of patient’s history and care across all facilities and admissions
CPOE (computerized provider order entry)
- provides efficient work flow
- automatically routes orders to appropriate clinical areas
- date and time automatically recorded
- notes always legible
- quick communication
- gives many providers access to info
- can reduce documentation time
- quick retrieval
- reimbursement is easier and faster
- high cost
- computer downtime can create major issues
11
Q
case management system charting
A
- organizes patient care through an episode of illness so clinical outcomes are achieved within an expected time frame and at a predictable cost
- a clinical pathway or interdisciplinary care plan takes the place of the nursing care plan
12
Q
EMR
A
electronic medical record
13
Q
EHR
A
electronic health record
14
Q
title for charting
A
E. Greene, SPN
(student practical nurse)
15
Q
PIE charting
A
P- problem identification
I- interventions
E- evaluation
16
Q
accuracy in documentation
A
- be specific and definite
- use words or phrases that convey the correct
meaning - words with ambiguous meanings and slang should not be used
17
Q
brevity in documentation
A
- articles may be omitted (a, an, the)
- use abbreviations, acronyms, symbols acceptable to the agency
- choose which behaviors and observations are noteworthy
18
Q
legibility and completeness in documentation
A
- if writing is not legible, misperceptions can occur
- include as much information as needed
- must see patient and document something at least every 2 hours (rounds)
- completeness is more important than brevity
19
Q
admission forms
A
20
Q
intake and output (I&O) record
A
21
Q
ancillary staff sheets
A
22
Q
consultation sheet
A
23
Q
diabetes care flow sheet
A
24
Q
discharge form
A
25
discharge planning sheet
26
fall risk assessment
27
frequent observations sheet
28
intravenous (IV) flow sheet
29
pain assessment
30
preoperative checklist
31
skin risk assessment
32
surgical or treatment consent form
33
time-out form
34
transfer form
35
medication administration record (MAR)
