Lecture 6

Question 1

Five Purposes for Documentation

Answer 1

1. Documented Communication
2. Permanent record for accountability
3. Legal record of care
4. Teaching
5. Research and data collection

Question 2

SBAR

Answer 2

Situation
Background
Assessment
Recommendation

Question 3

Purpose of the Chart

Answer 3

Permanent Account
Sharing Information
Quality Assurance
Accreditation
Reimbursement
Education and Research
Legal Evidence

Question 4

SOAPE

Answer 4

Subjective
Objective
Assessment
Plan
Evaluation

Question 5

Tips for Documentation

Answer 5

Use abbreviations appropriately (when in doubt, spell it out)
Use military time
Each thought is terminated with a period
Fill in all spaces, leave no blanks
Chart AFTER care is given
Chart only your own care and observations
Be OBJECTIVE, write only what you see, hear, feel and smell

Question 6

Legal Basis of Documentation

Answer 6

Best defense of legal claims
Inappropriate documentation may lead to nursing malpractice

Question 7

Legal Guidelines for Documentation

Answer 7

Do not erase
Draw a single line through error and follow policy
Do not document critical comments
Correct all errors promptly
Record all facts
Do not leave blank spaces
Record legibly

Question 8

Kardex

Answer 8

Consolidates patient orders and care needs in a concise way

Question 9

Nursing Care Plan

Answer 9

outlines the proposed nursing care based on the nursing assessment and care

Question 10

Flow Sheet

Answer 10

Includes weights, fluids, or IV therapy
Records frequent assessment data
Output, intake

Question 11

Incident Report

Answer 11

Any event not consistent with the routine pt care
Used when pt care was not consistent with facility or national standards
Provide objective, observed info
Do NOT admit liability or give unnecessary detail
Do NOT mention the incident report in the nurses notes
Is NOT included in the medical record