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MCN RLE PRELIMS > GUIDELINES IN EFFECTIVE DOCUMENTATION > Flashcards

GUIDELINES IN EFFECTIVE DOCUMENTATION Flashcards

1
Q

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).

A

Documentation

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2
Q

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

A

documentation

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3
Q

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

A

documentation

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4
Q

Communication

Planning Client Care

Auditing Health Agencies

Research

Education

Reimbursement

Legal Documentation

Health Care Analysis

A

Purposes Of Documentation

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5
Q

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

A

Reporting

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6
Q

based on the nursing process

A

Reporting

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7
Q

needed for continuity of care

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

A

Reporting & Documentation

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8
Q

Nurse must provide clear accurate & concise information

A

Telephone Reports & Orders

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9
Q

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
A

Telephone Reports & Orders

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10
Q

they may only receive telephone orders

A

Registered Nurses

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11
Q

telephone reports and order need to be verified by

A

reporting it clearly and precisely

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12
Q

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

A

countersigned; within 24 hours

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13
Q
  1. Use of Common Vocabulary
  2. Legibility
  3. Abbreviations & Symbols
  4. Organization
  5. Accuracy
  6. Documenting a Medication Error
A

Elements of Effective Documentation

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14
Q
  1. Confidentiality
  2. Factual
  3. Complete
  4. Current
  5. Organized
A

Elements of Effective Documentation

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15
Q

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

A

Use of Common Vocabulary

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16
Q

*Print if necessary

*Do not erase or obliterate writing

*State the reason for the error

*Sign and date the correction

A

Legibility

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17
Q

*Always refer to the facility’s approved listing

*Avoid abbreviations that can be misunderstood

A

Abbreviations & Symbols

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18
Q

*Start every entry with the date and time

*Chart in chronological order

*Chart medications immediately after administration

*Sign your name after each entry

A

Organization

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19
Q

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

*Use correct spelling and grammar

*Write complete sentences

A

Accuracy

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20
Q

*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

A

Documenting a Medication Error

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21
Q

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

A

Confidentiality

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22
Q

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

objective description is the result of direct observation & measurement

A

Factual

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23
Q

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

A

Complete

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24
Q

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
A

Current

25
Q
  • Communicate information in a
    logical order
  • It is effective when notes are
    concise, clear, and direct to the
    point
A

Organized

26
Q
  1. Admission Nursing Assessment
  2. Nursing Care Plan
  3. Kardex
  4. Pertinent information about patient
  5. Medication with date of order & time of administration
  6. Daily treatment & procedures
A

Types of Nursing Records

27
Q
  1. Flow charts
  2. Graphic record (TPRBP)
  3. Fluid balance record
  4. Standing Order Sheet
  5. Skin assessment record
  6. Progress notes
A

Types of Nursing Records

28
Q
  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
A

General Documentation Guidelines

29
Q
  1. Do not leave space in between entries
  2. If an errors is made while documenting, use a single line to cross out the error, then date, time & sign the correction
  3. Never change another person’s entry even if it is incorrect
  4. Use quotation marks to indicate direct client responses
A

General Documentation Guidelines

30
Q
  1. Document in chronological order
  2. Use permanent ink
  3. Document all telephone calls that you received that are related to client’s case.
A

General Documentation Guidelines

31
Q
  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
A

Correcting Errors

32
Q
  1. Follow your hospital policy
  2. 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
A

Correcting Errors

33
Q
  1. Kardex
  2. Flow Sheets
  3. Nurses’ Progress Notes
  4. Discharge Summary
A

Forms for Recording Data

34
Q

a shift and during change-of-shift reports.

used as a reference throughout the
client data ( e.g name, age, admission date,
allergy)

A

Kardex

35
Q

Medical diagnoses and nursing diagnoses

Medical orders, list of medications

Activities, diagnostics tests, or specific data of the patient.

A

Kardex

36
Q

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).

A

Flow Sheets

37
Q

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

A

Nurses’ Progress Notes

38
Q
  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.
A

Discharge Summary

39
Q

the acceptance of responsibility for personal
information protection

A

Accountability in relation to privacy

40
Q

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

A

accountable organization

41
Q

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

A

Accountability in relation to privacy

42
Q

Data Privacy Act of 2012

A

Republic Act 10173

43
Q

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.

A

SEC. 21. Principle of Accountability

44
Q

originates from “privatus” and “privo” in latin and means “deprive of”.

A

Concept of Privacy

45
Q

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

A

Patients’ Right to Privacy

46
Q
  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
A

Types of Documentation

47
Q

the traditional method for recording nursing care provided.

A

Narrative Documentation

48
Q

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

A

Narrative Documentation

49
Q

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

A

Problem-Orientated (SOAP)

50
Q

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

A

Problem oriented: PIE (problem, intervention, evaluation)

51
Q

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

A

Problem oriented: PIE (problem, intervention, evaluation)

52
Q

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

A

Focus Charting (FDAR)

53
Q

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

A

Charting by exception

54
Q

Charting is done intermittently if there are unexpected findings or events

A

Charting by exception

55
Q

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

A

Computerized Documentation

56
Q

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.

A

Computerized Documentation

57
Q

Increases the quality of documentation and save time

A

Computerized Documentation

58
Q

Increases legibility and accuracy

Facilitates statistical analysis of data

A

Computerized Documentation

MCN RLE PRELIMS (5 decks)

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