Intro to the Nursing Domain Documenting and Reporting Lecture 2 Flashcards

1
Q

What are the Joint Commission requirements for patient documentation?

A
Timely
Accurate 
Complete
Confidential
Specific to client
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2
Q

what is the ANA Code of Ethics?

A

Duty to maintain confidentiality

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3
Q

defined as communicating specific info about aspects of client care (usually done verbally)

A

Reporting

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4
Q

What are the different type of reports?

A
change of shifts
telephone reports
care planning conferences
nursing rounds
physician rounds
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5
Q

What is the purpose of documenting ?

A
for...
communication
planning care
quality assurance 
legal accountability
reimbursement
health care analysis/research
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6
Q

what type of information does admission notes documentation cover?

A
patient arrival
comprehensive nursing history 
complete physical assessment
chief complaint 
treatments in progress
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7
Q

what type of information does assessment notes documentation cover?

A

current client status
beginning of shift (completed then)
maybe by narrative, flow sheet or charting by exception
*ongoing

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8
Q

What type of information can be found on a flow sheet?

A

Intake and output
medication administration record
client teaching

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9
Q

what type of information can be found on progress notes?

A

provide information about progress toward outcomes
document problems or refusal of treatments
notification of physician

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10
Q

When describing observations it is best to use what type of data?

A

Objective

subjective data can be used by must be indicated by quotation marks or by stated by

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11
Q

When describing symptoms be sure to be descriptive of …

A

location, duration, intensity, amount, size and frequency

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12
Q

when describing psycho-social status be sure to…

A

describe specific behaviors and use quotes rather than judgments

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13
Q

What are some examples of documentation formats

A
narrative charting
problem-focused charting
charting by exception
flow sheets 
graphic records
nursing care plans
kardex/worksheets
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14
Q

What are the general guidelines for recording ?

A
date and time
timing (exact time, do not pre-chart)
legibility
permanence (black ink)
accepted terminology and abbreviations 
correct spelling and grammar
signature
legal prudence
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15
Q

This type of reporting requires one to be concise and includes…basic identifying information and medical diagnosis, reason for admission for new patients, significant changes in client condition, abnormal assessment findings/vital signs, last pain medication and time, priorities of care of due on shift, important individualized care needs, and etc

A

Change of shift

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16
Q

this type of reporting format is referred to as SBAR

A

Situation (what is going on with the patient)
Background (what is the patients pertinent history)
Assessment (what do you think is going on)
Recommendation (what do you think needs to be done)

17
Q

Is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice

A

Nursing Informatics