Lecture 8 - Documentation and Medication Administration Flashcards
What is documentation?
The process of documenting nursing information about nursing care in health records
What is the difference between an electronic health and electronic medical record?
An EMR stays in the hospital is was recorded at, an EHR is a digital long-term record of an individual’s health
Which legislation protects confidentiality?
Personal Information Protection and Electronic Documents Act (PIPEDA)
Documentation must be:
Factual, Accurate, Complete, Current, Organized, and Compliant with Standards
What is narrative documentation?
Traditional method, all information recorded.
What is a problem-oriented health care record?
A database with a problem list, care plan, and progress notes
What are source records?
When each discipline (i.e., nursing, physio, MD) charts in a separate section
What is charting by exception?
Progress notes written only when the standardized statement is not normal
What is a care map?
A flow sheet or nursing plan the eliminates the need for nurse’s notes.
What does the acronym DAR stand for?
Data, Action, Response
Sometimes referred to as F-DAR (focus)
What does the acronym PIE used for?
Problem, Intervention, Evaluation
What does the acronym SOAPIE(R) stand for?
Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision of plan
Which four things must the court be satisfied about for documentation to be used as evidence?
- Notes were made by person testifying
- It was part of the nurse’s duty to make notes
- Notes were made contemporaneously with event (or reasonably so)
- There have been no alternation, additions, or deletions to the notes.
What does the acronym AC mean?
Before meals (ante cibum)
What does the acronym PC mean?
After meals (post cibum)
What does the acronym HS mean?
at bedtime (hora somni)
What does the acronym PRN mean?
As needed (pro re nata)
What does the acronym STAT mean?
Immediately (statum)
What does the acronym qh mean?
Every hour (quaque hora)
What does the acronym q2h mean?
Every 2 hours (quaque secunda hora)
What does the acronym q6h mean?
Every six hours (quaque sexta hora)
What does the acronym BID mean?
2x/day (bis in die)
What does the acronym TID mean?
3x/day (ter in die)
What does the acronym QID mean?
4x/day (quarter in die)
What is a Kardex?
A patient care summary
What is the role of expert witnesses?
To interpret the health care record and assist in court in reconstructing events.
They can be used by either the plaintiff or defense and are permitted to express an opinion and describe an appropriate standard of care and documentation.
When advising patients via telehealth, what must be documented?
- The person’s name and contact information
- The symptoms reported
- The advice or referrals given (and a time frame for follow up)
- The date and time of the call
What are the three principles of medication administration?
Authority, Competence, and Safety
Nurses accept orders that are _____, ___, and __
Clear, Complete, and Appropriate
Which three people are collectively responsible and accountable for medication administration?
The prescriber, pharmacist, and nurse.
What is the difference between STAT and Now orders?
STAT orders are to be performed immediately
Now order are to be given within 90 minutes.
What are the ten rights of medication administration?
- Right medication
- Right dose
- Right patient
- Right route
- Right time and frequency
- Right documentation
- Right reason
- Right to refuse
- Right patient education
- Right evaluation
A patient tells the nurse, “I have stomach cramps and feel
nauseated.” This is an example of which type of data?
A. Objective
B. Historical
C. Subjective
D. Biographical
C. Subjective
Which following scenario represents a breach of confidentiality and privacy?
A. A patient is allowed to see and get copies of their own medical record.
B. A nurse telephones the patient’s church to have the patient’s name placed on a prayer list.
C. A certified nursing assistant documents vital signs on a graphic sheet in
the patient’s chart.
D. A student nurse covers the patient’s identifying information while copying
the patient’s medication administration record and uses the copy to look up
the medications in a drug book while on the unit.
B. A nurse telephones the patient’s church to have the patient’s name placed on a prayer list.
Which is a method of charting in which the nurse writes a
progress note only when the standardized statement on the
form is not met?
A. Narrative method.
B. Source record.
C. Problem-oriented medical record.
D. Charting by exception.
D. Charting by exception.
The nurse is having difficulty reading a prescriber’s order for a
medication. The nurse knows that the prescriber is very busy
and does not like to be called. What should the nurse do?
A. Call a pharmacist to interpret the order.
B. Call the prescriber to have the order clarified.
C. Consult the unit manager to help interpret the order.
D. Ask the unit secretary to interpret the prescriber’s
handwriting.
B. Call the prescriber to have the order clarified.
The nurse is about to administer an antibiotic to a patient. The patient asks what the medication is and why the patient should take it. What should the nurse tell the patient?
A. Inform the patient that only the patient’s physician can give this
information.
B. Provide the name of the medication and a description of its desired effect.
C. Tell the patient that information about medications is confidential and cannot be shared.
D. Explain that because of the limits placed on unregulated care providers, the patient will have to speak with his assigned nurse about this.
B. Provide the name of the medication and a description of its desired effect.
