Module 8 - Documentation - Start of Final Exam

Question 1

Why is having the patient verbalize understanding improtant?

Answer 1

To document appropriately so when presented to others it is understood, and also incase the charting has to go to court - then that info needs to be actual and to the point

Question 2

Documentation

Answer 2

the written or electronic legal records of all pertinent interaction with the patient

Question 3

Patient Records

Answer 3

complete record of health information

Question 4

Purpose of Patient Records

Answer 4

Communication
Diagnostic and therapeutic orders
Care planning
Quality process and performance improvement
Research; decision analysis
Education
Credentialing, regulation, and legislation
Reimbursement
Legal and historical documentation

Question 5

5 Elements of Documentation

Answer 5

Content

timing

format

accountability

confidentiality

on page 459 know the terms**

Question 6

dont document until…

Answer 6

AFTER something is done

Question 7

Characteristics of Effective Documentation

Answer 7

Consistent with professional and agency standards
Complete
Accurate
Concise
Factual
Organized and timely
Legally prudent
Confidential

Question 8

Important DO NOT USE List Parts

Answer 8

U, u (for unit) –> use the word unit

IU (International Unit) –> spell it out

QD Q.D q.d. qd (Daily) –> write daily

QOD Q.O.D. q.o.d qod (every other day) –> write every other day

trailing zeroes –> write X mg

lack of leading zero –> write 0.X mg

MS –> write morphine sulfate or magnesium sulfate

MSO4 and MgSO4 –> write out since they are confused for one another

Question 9

What is Confidentiality?

Answer 9

All information about patients written on paper, spoken aloud, saved on a computer

ex:
Name, address, phone, fax, social security number

Reason the person is sick

Treatments patient receives
`
Information about past health conditions

Question 10

Potential Breaches in Patient confidentiality

Answer 10

Displaying information on a public screen

Sending confidential email messages via public networks

Sharing printers among units with differing functions

Discard copies of patient information in trash cans

Holding conversations that can be overheard

Faxing confidential forms to unauthorized persons
sending confidential messages over heard on pagers

Question 11

Patient Rights

Answer 11

1. See a copy of their health records
2. Update their health records
3. Get a list of disclosures
4. Request a restriction on certain use of disclosures
5. Choose how to receive health information

Question 12

The only time you can receive verbal orders is during an …

Answer 12

emergency (otherwise it must be written or electronic)

Question 13

Policy for Receiving Verbal Orders in an Emergency

Answer 13

Record the orders in patient’s medical records

Read back the order to verify accuracy

Date and note the time orders were issued in emergency

Record verbal order and name of the physician issuing the order, followed by nurse’s name and initials

Question 14

Policy for Physician Or Nurse Practitioner Review of Verbal Orders

Answer 14

Review orders for accuracy

Sign orders with name, title, and page number

Date and note time orders signed

Question 15

Duties for RN Receiving Telephone Orders

Answer 15

Record the orders in patient’s medical records

Read order back to practitioner to verify accuracy

Date and note the time orders were issued

Record telephone orders, and full name and title of
physician or nurse practitioner who issued the orders

Sign the order with name and title provider and then a slash with the nurse who is taking the order off (physician name and your name and title)

Question 16

Purpose of Recording Data

Answer 16

Facilitate quality, evidence-based patient care

Serve as a financial and legal record

Help in clinical research

Support decision analysis

Question 17

t.o.

Answer 17

telephone order

Question 18

2 Types of Personal health Records

Answer 18

1. Standalone Personal health records

2.tethered/connected personal health records

Question 19

Standalone Personal Health records

Answer 19

patients fill in information from their own records; the information is stored on patients’ computers or the internet

Question 20

Tethered / Connected Personal health Records

Answer 20

linked to a specific health care organization’s electronic health record (EHR) system or to a health plan’s information system

used more often now where patients can update via a link

Question 21

Benefits of health Information Exchange

Answer 21

Provides a vehicle for improving quality and safety of patient care

Provides a basic level of interoperability among EHRs maintained by individual physicians and organizations

Stimulates consumer education and patients’ involvement in their own health care

Helps public health officials meet their commitment to the community

Creates a potential look for feedback between health-related research and actual practice

Facilitates efficient deployment of emerging technology and help care services

Provides the backbone of technical infrastructure for leverage by national and state-level initiatives

Question 22

Methods of Documentation

Answer 22

Source-oriented records

Problem-oriented medical records

PIE charting (problem, intervention, evaluation

Focus charting

Charting by exception

Case management model

Computerized documentation/Electronic health records (EHRs)

Question 23

5 Major components of problem oriented medical records

Answer 23

1. Defined Database
2. Problem List
3. Care plans
4. progress notes
5. soap format

• this is organized around their proble

Question 24

Advantage of Problem Oriented Medical Record

Answer 24

entire team makes a master list of problems and contributes collaboratively and focuses in on the problem

Question 25

SOAP Format

Answer 25

Subjective Objective Assessment Plan

Question 26

Format for Nursing documentation

Answer 26

Initial nursing assessment

Care plan; patient care summary

Critical collaborative pathways

Progress notes

Flow sheets and graphic records

Medication records

Acuity records

Discharge and transfer summary

Long-term care and home health care documentation

Question 27

Types of Flow Sheets

Answer 27

Graphic records

24-hour fluid balance record

Medication administration record (MAR)

24-hour patient care record

Acuity records

Question 28

4 Medicare Requirements for home health care

Answer 28

1. Patient is homebound and still needs skilled nursing care
2. Rehabilitation potential is good (or patient is dying)

3.The patient’s status is not stabilized

4. The patient is making progress in expected outcomes of care

Question 29

4 Basic components of RAI (Resident Assessment tool)

Answer 29

1. minimum data set
2. triggers
3. resident assessment protocols
4. utilization guidelines

Question 30

RAI

Answer 30

Resident Assessment Tool

document for long term care which helps staff gain definitive information on a patients strengths and needs, allows for making an individualized care plan, help achieve and ID goals and make modifications

it helps the resident get the highest care and health possible and maintain individuality (also a part of QOC)

basically - its a document that helps facility to get paid for services and also helps ID what the patients strengths, weaknesses, and what they are capable of doing

Question 31

Benefits of RAI

Answer 31

Residents respond to individualized care

Staff communication becomes more effective resident and family involvement increases

Documentation becomes clearer

Question 32

Hand off communication in the hospital

Answer 32

ISBARR

Question 33

ISBARR

Answer 33

Identity / Introduction (who you are, why, where you are)

Situation (why is this hand off occurring to another unit)

Background (what led to this situation)

recommendation (what you would do to correct the issue)

Readback of roders/Response

Question 34

Change of Shift / Hand Off Reports

Answer 34

Info given from primary nurse to another:

Basic identifying information about each patient:

name, room number, bed, designation, diagnosis, and attending and consulting physicians

Current appraisal of each patient’s health status

Current orders (especially any newly changed orders)

Abnormal occurrences during the shift

Any unfilled orders that need to be continued onto the next shift

Patient/family question, concerns, needs

Report on transfers/discharge

Question 35

During a change of shift report what happpens?

Answer 35

The info is given in ISBARR format while the new nurse writes it down

Question 36

Telephone/Telemedicine Reports: Information to Know

Answer 36

Identify yourself and the patient, and state your relationship to the patient

Report concisely and accurately the change in the patient’s condition that is of concern and what has already been done in response to this condition

Report the patient’s current vital signs and clinical manifestations

Have the patient’s record at hand to make knowledgeable responses to any physician

Concisely record time and date of the call, what was communicated, and physician’s response

Question 37

Conferring About Care

Answer 37

Consultations and referrals

Nursing and interdisciplinary team care conferences

Nursing care rounds

Purposeful rounding

Question 38

Purposeful Rounding

Answer 38

Nurse EBP where the nurse goes room to room and gives information on each patient while involving them to reduce issues and increase patient satisfaction

Question 39

8 Behaviors of Purposeful Rounding

Answer 39

Use open key words (C-I-CARE) with PRESENCE

Accomplish scheduled tasks

Address four Ps

Address additional personal needs, questions

Conduct environmental assessment

Ask “is there anything else I can do for you? I have time”

Tell the patient when you will be back

Document the round