L2: Documentation Flashcards
A fundamental component of nursing activities such as assessment and care planning, accdg. to the various models which have been designed for these functions.
DOCUMENTATION
- Continuity of care
- Furnishes legal evidence of the process of care.
- Promotes and facilitates the evaluation of the quality of patient care delivery.
IMPORTANCE OF PROPER DOCUMENTATION
- Communication
- Planning client care
- Auditing health agencies
- Research
- Education
- Reimbursement
- Legal documentation
- Health Care Analysis
PURPOSES OF DOCUMENTATION
- Takes place when two or more people share information about client care, either face to face of by telephone.
- Based on nursing process.
REPORTING
Only ____ may receive telephone orders.
The order needs to be verified by reporting it clearly and precisely.
RNs
The order should be countersigned by the ________ which made the order within the prescribed period of time.
PHYSICIAN
Prescribed period of time
24 HOURS
- 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
THE NURSE MUST DOCUMENT THE FF:
Improves communication and lessens the chance of misunderstanding between members of the health team.
USE OF COMMON VOCABULARY
- Print if necessary.
- Do not erase or obliterate writing.
- State the reason for the error.
- Sign and date the correction.
LEGIBILITY
- Always refer to the facility’s approved listing.
- Avoid abbreviations that can be misunderstood.
ABBREVIATIONS & SYMBOLS
- Start every entry with the date and time.
- Chart in chronological order.
- Chart medications immediately after administration.
- Sign your name after each entry.
ORGANIZATION
- Use descriptive terms to chart exactly what was observed or done.
- Use correct spelling and grammar.
- Write complete sentences.
ACCURACY
Document in the nurse’s progress notes:
- Name and 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.
DOCUMENTING A MEDICATION ERROR
The nurse is responsible for protecting the privacy and confidentiality of client interactions, assessments, and care of client.
CONFIDENTIALITY
- A factual record contains descriptive, objective information about what a nurse sees, hears, feels, and smells.
- An objective description is the result of direct OBSERVATION and MEASUREMENT.
FACTUAL
The information within a recorded entry or a record must be complete, containing appropriate and essential information.
COMPLETE
- Timely entries are essential in patient’s ongoing care. Delay in documentation leads to unsafe patient care.
- Health organizations use military time to avoid misinterpretation of AM and PM.
CURRENT
- Communicate information in a LOGICAL order.
- It is effective when notes are concise, clear, and direct to the point.
ORGANIZED
A shift and during change-of-shift reports. It is also used as a reference throughout the client data. (e.g., name, age, admission date, allergy)
KARDEX
The information in this can be formatted to meet the specific needs of the client (e.g., graphic sheets for vital signs, intake & output record, skin assessment record).
FLOW SHEETS
Used to document the client’s condition, problems and complaints, interventions, responses, achievement of outcome.
NURSES’ PROGRESS NOTES
- Client’s status at admission and discharge
- Brief summary of client’s care
- Interventions and education outcomes.
- Resolved problems and continuing needs.
- Referrals
- Client instructions
DISCHARGE SUMMARY
In relation to privacy, is the acceptance of responsibility for personal information protection.
ACCOUNTABILITY
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.
RA 10173 - DATA PRIVACY ACT OF 2012
Originates from “privatus” and “privo” in latin and means “deprive of”.
THE CONCEPT OF PRIVACY
Involves the confidentiality of information related to the patient and bodily privacy of the patient.
“Disclosure of patients case patients name to diseases, only patient to doctor”
PATIENT’S RIGHT TO PRIVACY
