GUIDELINES IN EFFECTIVE DOCUMENTATION

Question 1

a fundamental component of nursing activities such as assessment and care planning, according to the various models which have been designed for these functions (Nazarko, 2007).

Answer 1

Documentation

Question 2

serves multiple and diverse purposes for nurses, for patients, and for the health profession

Answer 2

documentation

Question 3

ensures continuity of care, furnishes legal evidence of the process of care and promotes and facilitates the evaluation of the quality of patient care delivery

Answer 3

documentation

Question 4

Communication

Planning Client Care

Auditing Health Agencies

Research

Education

Reimbursement

Legal Documentation

Health Care Analysis

Answer 4

Purposes Of Documentation

Question 5

Takes place when two or more people share information about client care, either face to face or by telephone

Answer 5

Reporting

Question 6

based on the nursing process

Answer 6

Reporting

Question 7

needed for continuity of care

also a legal requirement showing the nursing care performed or not performed by anurse.

Answer 7

Reporting & Documentation

Question 8

Nurse must provide clear accurate & concise information

Answer 8

Telephone Reports & Orders

Question 9

The nurse must document the following:

• when the call was made
• who made the call/report
• who was called
• to whom information was given
• what information was given
• what information was received

Answer 9

Telephone Reports & Orders

Question 10

they may only receive telephone orders

Answer 10

Registered Nurses

Question 11

telephone reports and order need to be verified by

Answer 11

reporting it clearly and precisely

Question 12

The order should be _____ by the physician who made the order within the prescribed period of time of _____

Answer 12

countersigned; within 24 hours

Question 13

1. Use of Common Vocabulary
2. Legibility
3. Abbreviations & Symbols
4. Organization
5. Accuracy
6. Documenting a Medication Error

Answer 13

Elements of Effective Documentation

Question 14

7. Confidentiality
8. Factual
9. Complete
10. Current
11. Organized

Answer 14

Elements of Effective Documentation

Question 15

Improves communication & lessens the chance of misunderstanding between members of the health team

Answer 15

Use of Common Vocabulary

Question 16

*Print if necessary

*Do not erase or obliterate writing

*State the reason for the error

*Sign and date the correction

Answer 16

Legibility

Question 17

*Always refer to the facility’s approved listing

*Avoid abbreviations that can be misunderstood

Answer 17

Abbreviations & Symbols

Question 18

*Start every entry with the date and time

*Chart in chronological order

*Chart medications immediately after administration

*Sign your name after each entry

Answer 18

Organization

Question 19

*Use descriptive terms to chart exactly what was observed or done

*Use correct spelling and grammar

*Write complete sentences

Answer 19

Accuracy

Question 20

*Document in the nurse’s PROGRESS notes:

-Name & dosage of medication

-Name of the practitioner who was notified of the error

-Time of the notification

-Nursing interventions or medical treatment

-Client’s response to treatment

Answer 20

Documenting a Medication Error

Question 21

*The nurse is responsible for protecting the privacy and confidentiality of client interactions, assessments, and care of client

Answer 21

Confidentiality

Question 22

factual record contains descriptive, objective information about what a nurse sees, hears, feels & smells

objective description is the result of direct observation & measurement

Answer 22

Factual

Question 23

The information within a recorded entry or a record must be complete, containing appropriate and essential information

Answer 23

Complete

Question 24

Timely entries are essential in a patient’s ongoing care. Delay in documentation leads to unsafe patient care.

• Health organizations use military time to avoid misinterpretation of AM & PM

Answer 24

Current

Question 25

* Communicate information in a logical order * It is effective when notes are concise, clear, and direct to the point

Answer 25

Organized

Question 26

1. Admission Nursing Assessment 2. Nursing Care Plan 3. Kardex 3. Pertinent information about patient 4. Medication with date of order & time of administration 5. Daily treatment & procedures

Answer 26

Types of Nursing Records

Question 27

6. Flow charts 7. Graphic record (TPRBP) 8. Fluid balance record 9. Standing Order Sheet 10. Skin assessment record 11. Progress notes

Answer 27

Types of Nursing Records

Question 28

1. Ensure that you have the correct client record or chart 2. Document as soon as the client encounter is concluded to ensure accurate recall of data 3. Date and time of each entry 4. Sign each entry with your full legal name and with your professional credentials

Answer 28

General Documentation Guidelines

Question 29

5. Do not leave space in between entries 6. If an errors is made while documenting, use a single line to cross out the error, then date, time & sign the correction 7. Never change another person’s entry even if it is incorrect 8. Use quotation marks to indicate direct client responses

Answer 29

General Documentation Guidelines

Question 30

9. Document in chronological order 10. Use permanent ink 11. Document all telephone calls that you received that are related to client’s case.

Answer 30

General Documentation Guidelines

Question 31

1. If you spill something on the chart, do not discard notes. Recopy, put original and copied sheets in chart. Write “copied” on copy. 2. Do not scribble out charting 3. Avoid using “error” or “wrong patient” when making correction

Answer 31

Correcting Errors

Question 32

4. Follow your hospital policy 5. Do not alter charting, it is a legal document - Correct errors by drawing a single horizontal line through the error - Write the word error above the line, then sign your signature - No ink eradication, erasures or use of occlusive materials

Answer 32

Correcting Errors

Question 33

1. Kardex 2. Flow Sheets 3. Nurses’ Progress Notes 4. Discharge Summary

Answer 33

Forms for Recording Data

Question 34

a shift and during change-of-shift reports. used as a reference throughout the client data ( e.g name, age, admission date, allergy)

Answer 34

Kardex

Question 35

Medical diagnoses and nursing diagnoses Medical orders, list of medications Activities, diagnostics tests, or specific data of the patient.

Answer 35

Kardex

Question 36

information can be formatted to meet the specific needs of the client ( e.g: graphic sheets for vital signs, intake & output record, skin assessment record).

Answer 36

Flow Sheets

Question 37

Used to document the client’s condition, problems and complaints, interventions, responses, achievement of outcome.

Answer 37

Nurses’ Progress Notes

Question 38

1. Client’s status at admission and discharge 2. Brief summary of client’s care 3. Interventions and education outcomes 4. Resolved problems and continuing needs 5. Referrals 6. Client instructions.

Answer 38

Discharge Summary

Question 39

the acceptance of responsibility for personal information protection

Answer 39

Accountability in relation to privacy

Question 40

must have in place appropriate policies and procedures that promote good practices which, taken as a whole, constitute a privacy management program

Answer 40

accountable organization

Question 41

The outcome is a demonstrable capacity to comply, at a minimum, with applicable privacy laws.

Answer 41

Accountability in relation to privacy

Question 42

Data Privacy Act of 2012

Answer 42

Republic Act 10173

Question 43

Each personal information controller is responsible for personal information under its control or custody, including information that have been transferred to a third party for processing, whether domestically or internationally, subject to cross-border arrangement and cooperation.

Answer 43

SEC. 21. Principle of Accountability

Question 44

originates from "privatus" and "privo" in latin and means "deprive of".

Answer 44

Concept of Privacy

Question 45

involves the confidentiality of information related to the patient and bodily privacy of the patient.

Answer 45

Patients' Right to Privacy

Question 46

1. Narrative Documentation 2. Problem-Orientated (SOAP) 3. Problem oriented: PIE (problem, intervention, evaluation) 4. Focus Charting (FDAR) 5. Charting by exception 6. Computerized Documentation

Answer 46

Types of Documentation

Question 47

the traditional method for recording nursing care provided.

Answer 47

Narrative Documentation

Question 48

a story-like format to document information specific to client conditions and nursing care.

Answer 48

Narrative Documentation

Question 49

This type of charting focuses on the client’s problems and utilizes a structured approach to charting progress notes

Answer 49

Problem-Orientated (SOAP)

Question 50

are numbered or labeled according to the client’s problems.

Answer 50

Problem oriented: PIE (problem, intervention, evaluation)

Question 51

Resolved problems are dropped from daily documentation after the RN’s review. Continuing problems are documented daily.

Answer 51

Problem oriented: PIE (problem, intervention, evaluation)

Question 52

This method of documentation consists of notes that include data, both subjective and objective; action or nursing interventions; and response of the client. Data Action Response

Answer 52

Focus Charting (FDAR)

Question 53

was developed in response to problem-oriented charting as a means to free nurses from having to do extensive time-consuming charting

Answer 53

Charting by exception

Question 54

Charting is done intermittently if there are unexpected findings or events

Answer 54

Charting by exception

Question 55

More and more healthcare facilities are moving toward this for documentation.

Answer 55

Computerized Documentation

Question 56

In an ideal system, all parts of the system are integrated so that physician orders, laboratory reports, pharmacy requests, and nurses notes all use the same system and are cross-referenced.

Answer 56

Computerized Documentation

Question 57

Increases the quality of documentation and save time

Answer 57

Computerized Documentation

Question 58

Increases legibility and accuracy Facilitates statistical analysis of data

Answer 58

Computerized Documentation