Methods of Documentation - Documenting and Reporting Flashcards
Method traditionally used to record patient assessment and nursing care provided. It is simply the use of a storylike format to document information. In an electronic nursing information system, this is accomplished through use of free text entry or menu selections.
Narrative documentation
This documentation tends to be time consuming and repetitious. It requires the reader to sort through a lot of information to locate desired data. However, some nurses believe that in certain situations, use of this method provides better detail of individual patient assessment findings and/or complex patient situations.
Narrative
Physicians and other health care providers r___ nursing documentation for details about changes in a patient’s condition.
r-eview
One of the limitations of electronic documentation is the limited use of ___ documentation. Some areas of the EMR are designed to use multiple checkboxes or drop-down lists, which some believe may not adequately convey the details of significant events that result in a change in patient condition.
narrative
EMRs that incorporate options for ___ descriptions in a format that is easily retrieved and reviewed may enhance clinician communication and interdisciplinary understanding for patient care.
narrative
System of organizing documentation to place the primary focus on patients’ individual problems. Data are organized by problem or diagnosis. Ideally, each member of the healthcare team contributes to a single list of identified patient problems. This assists in coordinating a common plan of care.
Problem-oriented medical record (POMR)
Has the following major sections: database, problem list, care plan, and progress notes.
Problem-oriented medical record (POMR)
Section that contains all available assessment information pertaining to the patient (e.g., history and physical examination, nursing admission history and ongoing assessment, physiotherapist’s assessment, laboratory reports, and radiological test results).
Database
Provides the foundation for identifying patient problems and planning care. As new data become available, it is revised. It accompanies patients through successive hospitalizations or clinic visits.
Database
After analyzing data, healthcare team members identify problems and make a single ___ ___.
problem list
Includes a patient’s physiological, psychological, social, cultural, spiritual, developmental, and environmental needs. Team members list the problems in chronological order and file the list in the front of the patient’s record to serve as an organizing guide for patient care. Team members add and date new problems as they arise. When a problem has been resolved, the text of that problem is highlighted or lined out and the date is recorded.
Problem list
Disciplines involved in a patient’s care develop a ___ ___ or plan of care for each problem.
care plan
Nurses document the ___ of ___ in a variety of formats; generally, all of these formats include nursing diagnoses, expected outcomes, and interventions.
plan / care
Health care team members monitor and record the progress made toward resolving a patient’s problems in ___ notes. Health care providers write progress notes in one of several formats or structured notes within a POMR.
progress
One method is the subjective–objective–assessment–plan (SOAP) note. The acronym SOAP stands for ___ data (verbalizations of the patient), ___ data (that which is measured and observed), ___ (diagnosis based on the data), and ___ (what the caregiver plans to do). In some institutions, an “I” and an “E” are added (i.e., SOAPIE), for ___ and ___.
subjective / objective / assessment / plan / intervention / evaluation
The logic of the SOAPIE note format is similar to that of the nursing ___. The nurse collects data about a patient’s problems, draws conclusions, develops a plan of care, and then evaluates the outcome(s). Each SOAP note is numbered and titled according to the ___ on the list that it addresses.
process / problem
A second progress note m___ is the p___–i___–e___ (PIE) format.
m-ethod / p-roblem / i-ntervention / e-valuation
It is similar to SOAP charting in its problem-oriented nature. However, it differs from the SOAP method in that PIE charting originated in nursing ___, whereas SOAP charting originated from medical ___. T
practice / records
The ___ format simplifies documentation by unifying the care plan and progress notes. ___ notes differ from SOAP notes in that the narrative does not include a___ information. A nurse’s daily a___ data appear on flow sheets, preventing duplication of data. The narrative note includes the ___, the ___, and the ___. The PIE notes are numbered or labelled according to the patient’s p___. Resolved problems are dropped from daily documentation after the nurse’s review. Continuing problems are documented daily.
PIE X2 / a-ssessment x2 / problem / intervention / evaluation
The third format used for notes within a POMR is f___ charting. It involves the use of ___–___–___ (DAR) notes, which include ___ (both subjective and objective), ___ or nursing intervention, and ___ of the patient (i.e., evaluation of effectiveness).
f-ocus / data / action / response / data / action / response
This note addresses patient concerns: a sign or symptom, condition, nursing diagnosis, behaviour, significant event, or change in a patient’s condition Documentation in this format also follows the nursing process. This format enables nurses to broaden their thinking to include any patient c___, not just problem areas.
DAR / c-oncerns
F___ charting incorporates all aspects of the nursing process, highlights a patient’s concerns, and can be integrated into any clinical setting
F-ocus
In this, the patient’s chart is organized so that each discipline (e.g., nursing, medicine, social work, respiratory therapy) has a separate section in which to record data.
Source record
One advantage is that it allows caregivers to easily locate the proper section of the record in which to make entries.
Source record
Specific demographic data about patient: legal name, identification number, sex, age, birth date, marital status, occupation and employer, health card number, nearest relative to notify in an emergency, religious affiliation, name of attending physician, date and time of admission (part of the source record).
Admission sheet
Record of prescriber’s orders for treatment and medications, with date, time, and physician’s signature (part of the source record).
Order sheet
Summary of nursing history and physical examination (part of the source record).
Nurse’s admission assessment
Record of repeated observations and measurements such as vital signs, daily weights, and intake and output (part of the source record).
Graphic sheet and flow sheet
Results of initial examination performed by physician, including findings, family history, confirmed diagnoses, and medical plan of care (part of the source record).
Medical history and examination
Accurate documentation of all medications administered to patient: date, time, dose, route, and nurse’s signature (component of the source record).
Medication administration record (MAR)
Ongoing record of patient’s progress and response to therapy completed by all members of the healthcare team. Included in this section is a narrative record of the nursing process written by nurses: assessment, nursing diagnosis, planning, implementation, and evaluation of care (component of the source record).
Progress notes
Entries made into record by all health care–related disciplines: radiology, social work, laboratories, physiotherapy, and so forth (component of source record).
Health care disciplines’ records
Summary of patient’s condition, progress, prognosis, rehabilitation, and teaching needs at time of dismissal from hospital or healthcare agency (component of source record).
Discharge summary
A disadvantage of the ___ record is that details about a specific problem may be d___ throughout the record. For example, in the case of a patient with bowel obstruction, the nurse describes in the nurses’ notes the character of abdominal pain and the use of relaxation therapy and analgesic medication. In a separate section of the record, the physician’s notes describe the progress of the patient’s condition and the plan for surgery. The findings of X-ray examinations that reveal the location of the bowel obstruction are in the test results section of the record.
source / d-istributed
The nursing notes or interdisciplinary ___ notes section is where nurses enter a narrative description of nursing care and the patient’s response.
progress
Section for documenting care that is provided by the physician or nurse practitioner in the nurse’s presence. The nurse may record key diagnostic test results from other sections of the record in the nurses’ notes if they are of major importance in the care of the patient.
Progress notes
The philosophy behind ___ ___ ___ (CBE) is that a patient meets all standards unless otherwise documented.
charting by exception
Exception-based documentation systems incorporate standards of care, evidence-informed interventions, and clearly defined criteria for nursing assessment and documentation of “___” findings.
normal
The predefined statements used to document nursing assessment of body systems are called within defined limits (WDL) or ___ ___ ___ (WNL) definitions. They consist of written criteria for a “normal” assessment for each body system.
within normal limits
Automated documentation within a computerized documentation system allows nurses to select a ___ ___ ___ statement or to choose other statements from a drop-down menu that allow description of any assessment findings that deviate from the WDL definition or that are unexpected. The nurse writes a ___ note only when a patient’s assessment does not meet the standardized criteria for “___” in one or more body systems. When changes in a patient’s condition develop, the nurse needs to include a thorough and precise description of the effects of the change(s) on the patient and the actions taken to address the change(s) in the ___ note.
within normal (or defined) limits / progress / normal / progress
The case ___ model of delivering care incorporates an interdisciplinary approach to documenting patient care. In many organizations, the standardized plan of care is summarized into critical pathways for a specific disease or condition.
management
Interprofessional care plans that identify patient problems, key interventions, and expected outcomes within an established time frame.
Critical pathways
The document facilitates the integration of care because all healthcare team members use the same ___ ___ to monitor a patient’s progress during each shift or in the case of home care, every visit.
critical pathways
Many organizations summarize the standardized plan of care into critical ___ for a specific disease or condition. For example, in cancer care some ___ focus on malignancies that have a higher incidence, such as breast, colon, prostate, and lung cancers and certain types of blood cancers.
pathways x2
Evidence-informed critical ___ improve patient outcomes. For example, one critical ___ to manage pain caused by vascular-occlusive crisis in patients with sickle cell disease significantly improved the time interval between patient triage and administration of first analgesic dose and the likelihood of ketorolac administration in a pediatric emergency department.
pathways / pathway
Eliminate the need for nurses’ notes, flow sheets, and nursing care plans because the document integrates all relevant information.
Critical pathways
Unexpected occurrences, unmet goals, and interventions not specified within the clinical pathway time frame are called v___.
v-ariances
Present when the activities on the clinical pathway are not completed as predicted or the patient does not meet the expected outcomes.
Variance
An example of a negative v___ is when a patient postoperatively develops pulmonary complications necessitating oxygen therapy and monitoring with pulse oximetry. An example of a positive v___ is when a patient progresses more rapidly than expected (e.g., use of a Foley catheter may be discontinued a day early).
v-ariance x2
A variance a___ is necessary to review the data for trends and for developing and implementing an action plan to respond to the identified patient problems.
a-nalysis
May result from changes in the patient’s health or may occur as a result of other health complications not associated with the primary reason why the patient requires care.
Variances
Once a v___ has been identified, the nurse modifies the patient’s care to meet the needs associated with the v___.
v-ariance x2
