Lesson 9: Other Sources of Client Data

Question 1

Informal oral consideration of a subject
by two or more health care personnel to
identify a problem or establish strategies
to resolve a problem.
● Individual conference
● Handover, endorsement to HCPs
● Discussion about the condition of the
patient.

Answer 1

Discussion

Question 2

Oral, written, or computer-based
communication intended to convey
information to others.
● For instance, nurses always report on
clients at the end of a hospital work
shift.
● Ex. incidental report

Answer 2

Report

Question 3

● Also called chart or client record
● Formal, legal document that provides
evidence of a client’s care
● Can be written or computer based
● Although health care organizations use
different systems and forms for
documentation, all client records have
similar information.

Answer 3

Record

Question 4

The process of making an entry on a
client record.

Answer 4

Recording, Charting, or Documenting

Question 5

Each health care organization has
policies about recording and reporting
client data, and each nurse is
accountable for practicing according to
the standards. So agencies also indicate
which nursing assessments and
interventions can be recorded by
registered nurses and which can be
charted by unlicensed personnel.

Answer 5

Ethical and Legal Considerations

Question 6

Requires client record to be timely,
complete, accurate, confidential and
specific to the client.
● Healthcare reform has been pivotal in
the process of increasing the use of
electronic health records.

Answer 6

JCAHO

Question 7

the nurse has a duty to maintain
confidentiality of all patient information.”

The client’s record is also protected
legally as a private record of the client’s
care, so access to the record is
restricted to health personnel or
professionals

Answer 7

American Nurses Association Code of
Ethics (2001)

Question 8

Hallmark of nursing accountability is
accurate documentation of actions and
outcomes of delivered care is the
hallmark of nursing accountability.

Answer 8

Code of Ethics for Filipino Nurses

Question 9

regulations maintain the
privacy and confidentiality of Protected
Health Information

Answer 9

HIPAA

Question 10

Confidentiality of all patient information
● Client’s record protected legally as a
private record of client’s care
○ Legal document which can be
used against the nurse in the
court.
● Responsibility in using records for the
purpose of education and research

Answer 10

Ethical and Legal Considerations

Question 11

Accurate client record provides details about
the care a client has received and the client’s
overall response to care. So accurate
documentation provides the staff with a means
of accountability and reflection on the delivery
of client care

Answer 11

Purposes of Client Record

Question 12

Prevents fragmentation,
repetition, and delays in care.
○ Record serves as the vehicle by
which different health
professionals who interact with
the client communicate with each
other.

Answer 12

Communication

Question 13

Nurses use baseline and ongoing
data to evaluate effectiveness of
the care plan.
○ Each health professional uses
data from the client’s record to
plan care for that client, so a
primary care provider, for
example, may order a specific
antibiotic after establishing that
the client’s temperature is
steadily rising and the laboratory
tests reveal the presence of a
certain microorganism.

Answer 13

Planning client care

Question 14

Review client records for quality
assurance purposes. an
accrediting agency such as the
Joint Commission, may review
client records to determine if a
particular health agency is
meeting its stated standards.

Answer 14

Auditing Health Agencies

Question 15

Treatment plans for a number of
clients with the same health
problems can yield information
helpful in treating other clients.
○ The information contained in a
record can be a valuable source
of data for research

Answer 15

Research

Question 16

Students in health disciplines
often use client records as
educational tools. A record can
frequently provide a
comprehensive view of the client,
the illness, effective treatment
strategies, and factors that affect
the outcome of the illness.

Answer 16

Education

Question 17

Documentation also helps a
facility receive reimbursement
from the federal government. So
for a facility to obtain payment
through Medicare, the client’s
clinical record must contain the
correct diagnosis group codes
and reveal that the appropriate
care has been given
○ So codable diagnosis are
supported by accurate thorough
recording by nurses.

Answer 17

Reimbursement

Question 18

Admissible in court as evidence
unless client objects because
information client gives to
primary care provider is
confidential.

Answer 18

Legal Documentation

Question 19

Identify agency needs such as
overutilized and underutilized
hospital services.
○ Records can be used to establish
the cost of various services and
to identify those services that
cost the agency money and those
that generate revenue.

Answer 19

● Health Care Analysis

Question 20

Primary Source of Data

Answer 20

a. Patient

Question 21

a. Family members
b. Significant Others
c. Medical Records
d. Diagnostic Procedures
i. CBC, WBC, platelet,
sodium, potassium etc.

Answer 21

Secondary Source of Data

Question 22

a. Narrative Charting

Answer 22

1. Source-Oriented Record

Question 23

a. Database
b. Problem list
c. Plan of care
d. Progress Notes
● SOAP
● SOAPIER

Answer 23

Problem-Oriented Medical Record

Question 24

. legal name, birthday, age,
gender, SSS number, address,
marital status, closest relatives or
person to notify in case of
emergency, time date, and
admitting diagnosis, if there are
any food or drug allergies, name
of admitting primary care
provider, insurance information,
and any assigned diagnosis
related group.

Answer 24

Admission sheet

Question 25

. Findings from the Initial Nursing History and Physical Health Assessment

Answer 25

Initial Nursing Assessment

Question 26

body temperature, pulse rate, respiratory rate, blood pressure, the daily weight, and special measurements such as fluid intake and output and oxygen saturation

Answer 26

Graphic Record

Question 27

activity, diet, bathing and elimination record

Answer 27

Daily Care Record

Question 28

the Fluid balance record, skin assessment or the braden scale push tool

Answer 28

Special Flow Sheets

Question 29

name, dosage, drought, time, date of regularly administered medication, name or initials of persons administering the medication

Answer 29

Medication Record

Question 30

pertinent assessment of clients specific nursing care, including teaching and clients responses, clients complaints, and how client is coping

Answer 30

Nurse’s Notes

Question 31

past and family medical history, present medical problems, differential or current diagnosis, findings of physical examination by the primary care provider

Answer 31

Medical History and Physical Examination

Question 32

medical records for medications, treatments, and so on.

Answer 32

Physician’s order form

Question 33

a. observations of the doctors and the treatments given in the client's progress

Answer 33

Physician’s progress notes

Question 34

. records by medical and clinical specialist

Answer 34

Consultation record

Question 35

laboratory reports, CBC, sodium potassium, Xray reports, CT scan reports

Answer 35

Diagnostic reports

Question 36

physical therapies, and respiratory therapies. If your patients are referred to those other health care professionals.

Answer 36

Consultation reports

Question 37

started on admission and completed on discharge. So this includes nursing problems, general information and referral data

Answer 37

Client discharge plan and summary

Question 38

established by Lawrence Weed in the 1960 ● Data arranged according to client problems rather than the source of the information. ● Health team contributes to the problem list, plan of care, and progress notes. ● Plans for each active or potential problem are drawn in progress notes recorded for each problem.

Answer 38

Problem-oriented Medical Record

Question 39

All information known about the client when the client first enters the health care agency

Answer 39

Database

Question 40

Listed in order in which they are identified and others resolved ○ Derived from the database, it is usually kept at the front of the chart and serves as an index to the numbered entries in the progress notes

Answer 40

Problem List

Question 41

Made with reference to active problems ○ Generated by individual who lists the problems ○ Primary care providers - physicians orders or medical care plans, nurses - nursing orders or nursing care plans. ○ The written plan in the record is listed under each problem in the progress notes and is not isolated as a separate list of orders.

Answer 41

Plan of Care

Question 42

PIE

Answer 42

Problems 2. Interventions 3. Evaluation

Question 43

1. Data 2. Action 3. Response

Answer 43

Focus Charting

Question 44

Intended to make the client and client concerns and strengths the focus of care, so three columns for recording are usually used the date and time, focus, and progress notes. ● The focus may be a condition, a nursing diagnosis, a behavior or a sign or symptom, an acute change in the client's condition, or a client's strength.

Answer 44

Focus Charting

Question 45

Documentation system in which only abnormal or significant findings or exceptions to norms are recorded.

Answer 45

Charting by Exception (CBE)

Question 46

include graphic records of vital signs, braden assessment tool for the skin

Answer 46

Flow Sheets

Question 47

These are documentation by reference to the agency's printed standards of nursing practice eliminates much of the repetitive charting of routine care

Answer 47

Standards of Nursing Care

Question 48

So if all of the standards are not implemented,

Answer 48

an asterisk on the flow sheet is made with reference to the nurse's notes for all exceptions to the standards are described in narrative form on the nurses notes

Question 49

In the CBE system, all flow sheets are kept at the client's bedside to allow immediate recording and to eliminate the need to transcribe data from the nurse's worksheet to the permanent record.

Answer 49

Bedside access to chart forms

Question 50

Used to manage the huge volume of information required in contemporary health care, so that is, the EHR can integrate all pertinent client information into one record

Answer 50

Electronic Health Records (EHR)

Question 51

Emphasizes quality ● Cost effective care delivered within an established length of stay. ● This model uses a multidisciplinary approach to planning and documenting client care using the critical pathways. So these forms identify the outcomes of care along with the interventions necessary for each day.

Answer 51

Case Management

Question 52

a goal that is not met is called a is a deviation from what was planned on the critical pathway.

Answer 52

variance.

Question 53

It is the knowledge of events in the patient's illness, progress in his or her recovery and the type of care given by the hospital personnel. ○ This is the chart of the patient itself.

Answer 53

. Patient Clinical records

Question 54

A separate set of records is needed for each staff member, giving details of their sickness and absences, their career and development activities and a personal note. ○ Records of each staff in the unit. So each staff will have their own clearbook with names, leave, personal data sheet, achievement within the year, if they undergo Masters or PhD.

Answer 54

Individual Staff Records

Question 55

These are the records pertaining to a particular ward. i. Circular record ii. Round book iii. Duty roaster iv. Ward indent book v. Ward inventory book vi. Staff patient assignment record vii. Student attendance and patient assignment record

Answer 55

Ward Records

Question 56

○ Treatment register ○ Admission and discharge register ○ Personnel performance register ○ Organizational chart ○ Job description ○ Procedure manual

Answer 56

Administrative Records with Educational Value

Question 57

The client record should describe the client's ongoing status and reflect the full range of the nursing process, regardless of the record system used in an agency. So nurses document evidence of the nursing process in a variety of forms throughout the clinical report

Answer 57

Documenting Nursing Activities

Question 58

allow you to quickly and easily enter assessment data about a patient ○ It helps team members quickly see patient trends over time and decrease time spent on writing narrative notes

Answer 58

Flow Sheets and Graphic Records

Question 59

Body temperature, pulse, respiratory rate, blood pressure, weight, other significant clinical data such as admission or postoperative day bowel movements, appetite and activity

Answer 59

Graphic Records

Question 60

All routes measured and recorded

Answer 60

● Intake and Output

Question 61

Date of order, expiration date, name and dose, frequency and route of administration, nurse's signature ○ some records also include a place to document the client's allergies

Answer 61

Medication administration record

Question 62

Concise method of organizing and recording data making information quickly accessible to all health professionals

Answer 62

Kardex

Question 63

joint Commission requires clinical record to include: ● Evidence of client assessment ● Nursing diagnosis ● Nursing interventions ● Client outcomes ● Current nursing care plans

Answer 63

Nursing Care Plan

Question 64

Written for each client ○ The form varies from agency to agency according to the needs of the client and the department. So most forms have three columns, one for the nursing diagnosis, second for expected outcomes, and third for nursing interventions.

Answer 64

Traditional Care Plan

Question 65

Based on institutions standards of practice ○ Developed to save documentation time, so these plans may be based on an institution's standards of practice, thereby helping to provide high quality nursing care for the patient. So standardized plans must be individualized by the nurse in order to adequately address individual clients needs.

Answer 65

Standardized care plans

Question 66

Completed when client discharged ○ Terms that can be readily ○ Understood ● Completed when client transferred to another institution to a home setting where a visit by a community health nurse is required.

Answer 66

Discharge Summary Forms

Question 67

So if the client is being transferred to another institution or to a home setting where a visit by a home health nurse is required. So the discharge note

Answer 67

takes the form of a referral summary