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Nurs 202 > Lecture 2 Documentation > Flashcards

Lecture 2 Documentation Flashcards

1
Q

Documentation

A
  • Detailed account of quality of care
  • Communicate pt info accurately and timely effective manner
  • Didn’t chart it, didn’t happen
  • Record = Chart
  • Confidentiality
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2
Q

Confidentiality

A

Legal and Ethical obligations

Protect info:

  • Don’t leave it in a public area
  • Sign off the computer
  • Don’t be yapping around
  • Don’t leave anything that has your patient’s info
  • Don’t email client info
  • Shred all the proper information don’t take anything home
  • Don’t speak to anyone over the phone
  • Don’t post anything on social media

Health information privacy act (HIPA)- provincial legislation

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3
Q

Health information privacy act (HIPA)

A

-Came about in 1997
-Proclaimed in court in 2003
-Protecting the privacy of your health information
•States the rights of individuals and obligations of workers in a health system remains confidential

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4
Q

Purpose of a Health Record (chart):

A

More then just communication and care planning

  • Legal Document
  • Education (using data for audits)
  • Funding and Resource Management
  • Research
  • Quality Review
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5
Q

Health Records contain the following:

A 
o	Patient demographics
o	Admission nursing database
o	Nursing care plans
o	Nursing notes
o	Medical history
o	Medical diagnosis
o	Orders
o	Progress notes
o	Test reports
o	Operative notes
o	Discharge plan and summary
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6
Q

Types of Records

A

Source orientated Record

Problem Orientated

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7
Q

Source Orientated Record

A
  • Organised under separate disciplines
  • Each discipline has section
  • Not chronological
  • Must go to different sources to read same topic
  • Repetitive
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8
Q

Problem Orientated

A
  • data organized by pt problems
  • medically based format
  • Health Care members contribute to a single list of identified pt problems:
  • chronically ill pt
  • Pt with many problems
  • All members take care of same problem
  • Comprehensive individualized care
  • Issue: Multiple problems with the same symptoms
  • Problem focused
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9
Q

Ways to document nursing care

A
  • Narrative (source)
  • SOAP (problem)
  • PIE (problem)
  • Focus Charting (problem)
  • Chart by exception (problem)
  • Case management
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10
Q

Narrative (source)

A
  • Story
  • time consuming
  • Lots of info
  • What is relevant
  • Client Reponses
  • Oriented = Person place and time
  • See Mar = see medication record
  • O/M = Observation and measurement
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11
Q

SOAP (problem)

A

Subjective (pt remarks)

Objective (vital signs)

Assessment (nursing diagnosis)

Plan (resolution)

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12
Q

SOAPIER (problem)

A 
Subjective
Objective
Assessment
Plan
Intervention
Revision
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13
Q

PIE

A

Problem (diagnosis)
Intervention
Evaluation

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14
Q

Focus Charting (problem)

A

Based on pt Concerns

Uses DAR:
Data
action
Response

Pt Centered
Used for narrative
Flow chart

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15
Q

Chart by exception (problem)

A

Document deviations from the normal (saves time)

CBE

Based on set standards that have been met

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16
Q

Case management

A

Critical pathway = care maps

Multidisciplinary

Efficient

Computerized

Tailored to specific disease

17
Q

Admission Database

A

Complete initial nursing assessment of pt on admission

18
Q

Standardized Care plan:

A

Standardized form with some individualization

19
Q

Kardex (temp record)

A

Basic pt care summary

20
Q

Flowsheets and graphic records:

A

Records for quick data entry

21
Q

Discharge Summary:

A

Includes discharge info and instructions

22
Q

Incident Reports

A 
Involved in or witness
near miss
no blame 
-med errors
-incidents
23
Q

What do we document:

A
  • Care that you have provided
  • Patient status (vital signs)
  • Changes in patient status
  • Medication administration
24
Q

Documentation guidelines

A 
•	Date and time (24-hour clock)
•	Be timely
•	Use logical order
•	Meet set standards 
•	Write legibly in blue or black ink
•	Use accepted Abbreviations/symbols
•	Spelling and grammar
•	Sign all entries
o	Name and title: S. Akinfiresoye, UofS NS
•	Stick to the facts
o	Descriptive and objective
•	Be current and organized
o	Timely and well laid out
•	Be compliant with standards
o	Documenting what is done
•	Be accurate, specific, complete
25
Q

DO NOT:

A

• Never erase or use whiteout
• Janet IV was displaced after her shower is in situ.
Error O, Akinfiresoye NS Sept 13/18
• Never leave blank spaces in your notes
• Only chart your own actions – if you did not give the med you do not sign off on it
• DO not “prechart”
• Begin with date and time, end with signature and role (ie O. Akinfiresoye, UofS, NS)

Nurs 202 (20 decks)

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