Guidelines for Quality Documentation and Reporting - Documenting and Reporting Flashcards
Nursing documentation too often consists of a list of ___ performed and the production of quality documentation can be a challenge for nurses.
tasks
Quality documentation has six important characteristics: it is fa___, ac___, co___, cu___, and or___, and it co___ with standards set by Ac___ Canada and by provincial or territorial regulatory bodies.
factual
accurate
complete
current
organized
compliant / Ac-creditation
Quality docutmentation:
- Stick to the ___
- Writing in ___ sentences
- Using ___, short words
- Avoiding the use of jargon or a___
facts
short
simple
a-bbreviations
A ___ record contains descriptive, objective information about what a nurse sees, hears, feels, and smells. Avoid vague terms such as appears, seems, or apparently. These words suggest that you are stating an ___; they do not communicate ___ accurately and do not inform another caregiver of the details regarding the behaviours exhibited by the patient.
factual / opinion / facts
Objective data are obtained through direct observation and m___ (e.g., “BP 80/50, patient diaphoretic, heart rate 102 and regular”).
m-easurement
___ documentation includes the observations of the patient’s behaviours.
Objective
The only subjective data that you include in the record is what the patient ___. When recording subjective data, you document the patient’s exact words within ___ marks wherever possible. Include objective data to support subjective data so your documentation is as descriptive as possible. For example, instead of documenting “the patient seems anxious,” provide objective signs of anxiety and document the patient’s statement about the feeling(s) experienced (e.g., “the patient’s pulse rate is 110/beats/min, respiratory rate is slightly laboured at 22 breaths/min, and the patient states ‘I feel very nervous’ ”).
says / quotation
The use of exact measurements establishes a___ and helps the nurse determine if a patient’s condition has changed in a positive or negative way. For example, a description such as “intake, 360 mL of water” is ___ accurate than “Patient drank an adequate amount of fluid.”
a-ccuracy / more
Documenting that an abdominal wound is “5 cm in length without redness, drainage, or edema” is ___ descriptive than “large wound healing well.” Documentation of concise data should be clear and easy to understand. Avoid the use of unnecessary words and i___ detail. For example, the fact that the patient is watching TV is only necessary when this activity is significant to the patient’s status and plan of care.
more / i-rrelevant
Most health care institutions develop a list of standard ___, symbols, and acronyms to be used by all members of the healthcare team in documenting or communicating patient care and treatment. Approved abbreviations and acronyms vary, depending on the type of facility (i.e., long-term versus acute care facility). Use of an institution’s accepted abbreviations, symbols, and system of measures (e.g., metric) ensures that all staff members use the same language in their reports and records. Always use ___ carefully to avoid misinterpretation. For example, “od” (every day) can be misinterpreted to mean “O.D.” (right eye). If abbreviations are confusing, to minimize errors, you should spell terms out in their e___.
abbreviations x2 / e-ntirety
Has published an extensive list of error-prone abbreviations, symbols, and dose designations that health care institutions need to consider adding to their “Do Not Use” lists. Suggestions include writing “unit” instead of “U”, always using a zero before a decimal point in a decimal fraction (e.g., “0.25 mg”), and not writing a zero alone after a decimal point (e.g., writing “5 mg,” not “5.0 mg”).
Institute for Safe Medication Practices (ISMP)
Correct s___ demonstrates a level of competency and attention to detail. Many terms can easily be misinterpreted (e.g., dysphagia and dysphasia). Some s___ errors can also result in serious treatment errors (e.g., the names of certain look alike–sound alike medications, such as morphine and hydromorphone, are similar). Transcribe medication names carefully to ensure that patients receive the correct medication.
s-pelling x2
Record entries must be ___, and a method for ___ the authors of entries must be in place. Each entry in a patient’s record ends with the caregiver’s full name or initials and credentials/title/role such as “Holly Lee, LPN.” If initials are used in a signature, the full name and credentials/title/role of the individual need to be documented at least ___ in the medical record to allow others to readily identify the individual. As a nursing student, enter your full name and student nurse (SN) abbreviation, such as “Henri Gauthier, SN.” The abbreviation for student nurse varies between SN/___ for student nurse/student practical nurse or NS/___ for nursing student/practical nursing student. Include your educational institution when required by agency policy.
dated / identifying / once / SPN /PNS
Accountability is best accomplished when you chart only your ___ observations and actions. Your signature holds you accountable for information recorded.
own
Late entries are often documented by writing the current date and time in the next available space as close to the late entry as possible and writing “late entry for [___ and shift].” For adding information to an existing entry, using the current date and time in the next space and adding “add___ to note of [___ and time of prior note]” is a good practice.
date / add-endum
The information within a recorded entry or a report must be ___ containing appropriate and essential information. It is important to document all nursing ___, such as education and psychosocial support, as this information and the outcomes of these ___ are not often recorded in nursing documentation.
complete / interventions x2
An example of a thorough nurse’s note (subjective assessment data) is as follows:
Patient’s description of episode in ___ marks; for example, “I feel as if I have an elephant sitting on my chest and I can’t catch my breath.”
D___ in patient’s own words the onset, location, description of condition (severity, duration, frequency; precipitating, aggravating, and relieving factors) (e.g., “The pain in my left knee started last week after I knelt on the ground. Every time I bend my knee, I have a shooting pain on the inside of my knee.”)
quotation
D-escribe
Rash, tenderness, breath sounds, or descriptions of patient behaviour (e.g., anxiety, confusion, hostility).
Objective assessment data
An example of a thorough nurse’s note (objective assessment data) is as follows:
Onset, location, description of c___ (e.g., 1100 hrs: 2 cm raised pale red area noted on back of left hand).
Onset, precipitating factors, b___ exhibited (e.g., pacing in room, avoiding eye contact with nurse), patient statements (e.g., repeatedly stating, “I have to go home now.”)
c-ondition
b-ehaviours
Treatments and evaluation (e.g., enema, bath, dressing change).
Nursing interventions
An example of a thorough nurse’s note (nursing interventions) is as follows:
T___ administered, equipment used (if appropriate), patient’s r___ (___ and ___ changes) compared to previous treatment (e.g., denied incisional pain during abdominal dressing change, ambulated 100 metres in hallway without assistance).
T-ime /r-esponse / objevtive / subjective
An example of a thorough nurse’s note (medication administration) is as follows:
At ___ of administration when using a computerized bar-code medication administration program (or ___ after administration), document time medication given, medication n___, d___, r___, preliminary assessment (e.g., pain level, vital signs), patient r___, or effect of medication. For example:
1500 hrs: Reports “throbbing headache all over my head.” Rates pain at 6 (scale 0 to 10). Tylenol 650 mg given PO.
1530 hrs: Patient reports pain level 2 (scale 0 to 10) and states, “the throbbing has stopped.”
time / immediately / n-ame / d-ose / r-oute /r-esponse
An example of a thorough nurse’s note (patient and/or family teaching) is as follows:
Information pre___; method of in___ (e.g., discussion, demonstration, videotape, booklet); and patient r___, including questions and evidence of ___ such as re___ demonstration, or change in behaviour.
pre-sented / in-struction / r-esponse / understanding / re-turn
An example of a thorough nurse’s note (discharge planning) is as follows:
M___ patient goals or expected ___, progress toward goals, need for re___.
M-easurable / outcomes / re-ferrals
Means of entering current information quickly.
Flow sheets
The following activities and findings should be communicated at the time of occurrence:
- V___ signs
- P___ assessment
- A___ of medications and treatments
- Preparation for diagnostic tests or surgery, including preoperative checklist
- C___ in patient’s status and who was notified (e.g., nurse practitioner, physician, manager, patient’s family)
- Admission, transfer, discharge, or death of a patient
- T___ for a sudden change in patient’s status
- Patient’s r____ to treatment or i___
V-ital
P-ain
A-dministration
C-hange
T-reatment
response / intervention
Most healthcare agencies this 24-hour system that avoids misinterpretation of “a.m.” and “p.m.” times.
Military time
As a nurse, you want to communicate information in a logical order. For example, an ___ note describes the patient’s p___, the nurse’s a___ and i___, and the patient’s r___. To write notes about complex situations in an ___ manner, think about the situation and make notes of what is to be included before you begin to write in the permanent legal record.
organized / p-ain / a-ssessment / i-nterventions / r-esponse / organized
Documentation needs to follow standards set by ___ ___ and by provincial or territorial regulatory bodies to maintain institutional accreditation and to decrease the risk of liability.
Accreditation Canada
Current ___ require that all patients who are admitted to a health care institution undergo physical, psychosocial, environmental, and self-care assessments; receive patient education; and be provided discharge planning. In addition, criteria for ___ stress the importance of evaluating patient ___, including the patient’s response to treatments, teaching, or preventive care.
standards x2 / outcomes
The nursing service department of each health care agency selects a method of documenting patient care. The method reflects the philosophy of the nursing department and incorporates the ___ of care. Because the nursing process shapes a nurse’s approach and direction of care, effective ___ also reflects the nursing process.
standards / documentation
