Intro to the Nursing Domain Documenting and Reporting Lecture 2 Flashcards
What are the Joint Commission requirements for patient documentation?
Timely Accurate Complete Confidential Specific to client
what is the ANA Code of Ethics?
Duty to maintain confidentiality
defined as communicating specific info about aspects of client care (usually done verbally)
Reporting
What are the different type of reports?
change of shifts telephone reports care planning conferences nursing rounds physician rounds
What is the purpose of documenting ?
for... communication planning care quality assurance legal accountability reimbursement health care analysis/research
what type of information does admission notes documentation cover?
patient arrival comprehensive nursing history complete physical assessment chief complaint treatments in progress
what type of information does assessment notes documentation cover?
current client status
beginning of shift (completed then)
maybe by narrative, flow sheet or charting by exception
*ongoing
What type of information can be found on a flow sheet?
Intake and output
medication administration record
client teaching
what type of information can be found on progress notes?
provide information about progress toward outcomes
document problems or refusal of treatments
notification of physician
When describing observations it is best to use what type of data?
Objective
subjective data can be used by must be indicated by quotation marks or by stated by
When describing symptoms be sure to be descriptive of …
location, duration, intensity, amount, size and frequency
when describing psycho-social status be sure to…
describe specific behaviors and use quotes rather than judgments
What are some examples of documentation formats
narrative charting problem-focused charting charting by exception flow sheets graphic records nursing care plans kardex/worksheets
What are the general guidelines for recording ?
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
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
Change of shift
