Lecture: Documentation/Reporting Flashcards
What is the admission nursing history form?
A record-keeping form that guides nurses through a complete assessment to identify relevant nursing diagnoses or problems
When does discharge planning begin?
On admission
What do flow sheets and graphic records accomplish?
They allow team members to see trends over time
What is a Kardex?
A portable “flip-over” file with necessary patient information
What are standardized care plans?
Preprinted, established guidelines used to care for patient’s with similar conditions
What is an acuity record?
Not part of the patient’s medical record, but helps determine staffing levels. Acuity levels range from 1 to 5, with an acuity level of 5 representing a relatively stable patient and an acuity of 1 representing a patient that needs many nursing interventions.
What do you begin and end all your documentation with?
Begin with date/time and end with signature/title
When should you use the SBAR format?
During any kind of hand-off, change of shift, or telephone report
What is charting by exception?
Documenting only when something falls outside of the norm
What is a problem-oriented medical record?
Data is organized by creating a list of patient’s problems or diagnoses
What should you always do before letting the doctor off the phone when taking a telephone order
Read back the order to the doctor
What should you include in a change of shift report?
Basic info, current assessment, changes in medical condition, where patient stands in relation to goal, current orders
SBARQ
Situation (why am I calling), Background (what will the provider want to know) Assessment (what is my evaluation of the current status), Recommendation (what do I want), Questions
How do you sign a verbal order?
Write VO along with your signature/title and the doctors initials
How do you sign a telephone order?
Write TO along with your signature/title and the doctor’s initials
