Nursing Documentation and Nursing Process Flashcards
Name 5 reasons for charting
- COMMUNICATION-
- CONTINUITY-
- ACCOUNTABILITY-
- QUALITY ASSURANCE
- INFORMATION
When Planning interventions/outcomes, you need:
- Subject:“the pt”
- Action Verb: “will walk”
- Performance Criteria (measurable): “length of hallway”
- Target time: “1 week”
- Special Considerations: “using a walker”
What is nursing documentation?
- anything written or printed that is relied on as record or proof for authorizedpersons (health care providers).
- important source ofreference and communication between nurses and other health careproviders.
What are some Guidelines for Effective Documentation and Reporting?
- Factual
* Accurate
* Complete
* Current
* Organized
* Complies with standards
Name some methods of charting
- Narrative Charting
- SOAPIE
- PIE
- SOAPIER
- DAR
- Problem Oriented Medical Record (POMR)
- Acuity Charting
- Focus Charting
What does SOAP charting involve?
Subjective data
Objective data
Assessment
Plan
What does the PIER involve in SOAPIER?
P - problem:
I - intervention:
E - evaluation:
R (revision)
What is DAR charting?
Data
Action
Response
What is Problem Oriented Medical Record (POMR) charting?
method of documentation that emphasizes client’s problem
What is acuity charting?
provides a method of determining the hours of care and staff required for a given group of clients
What is focus charting?
movement away from charting only problems which has a negative connotation
What is KARDEX?
client care summary
- portable file containing flip cards
- objective: provide continuity of care from one shift to another
What type of data is found in the Kardex?
○ patient’s name, age, occupation, doctor, date of admission, diagnosis, surgery & emergency contact
○ basic dietary, activity, and hygiene needs
○ Allergies Diagnostic tests
○ Respiratory therapy treatments
○ Intravenous therapy
○ Daily nursing procedures including dressing changes, and vital signs
○ Medications
What is a MAR sheet?
Medication Administration Record
• record the administration of medications
medications are typically classified as routine or PRN
discuss discharge planning documentation
- started at the time the patient is admitted, and is completed at discharge
- lists the discharge planning and teaching that took place since the patient was admitted, and documents the patient’s condition at the time of discharge.
- also lists instructions concerning care after discharge.
What is Computer-Based Patient Care Record?
electronic health record and documentation system
What is a Nursing Process?
• is a systematic approach thatapplies knowledge from the biological, physical, and social sciences to unique client situations.
•
is used to identify, diagnose, and treat human responses to health and illness.
- involves five steps (ADPIE)
- helps nurses organize and deliver nursing care
What are the 5 steps in the nursing process?
○ assessment, ○ nursing diagnosis, ○ planning, ○ implementation ○ evaluation
A fellow nursing student is a patient in the hospital where you have your clinical placement. You became aware of his admission when you transferred your own patient to his unit today. What should you do?
1) Keep the information to yourself
2) Advise a few of his friends so that they can visit him
3) Visit him on his unit during your lunch break
4) Access his EHR to see if he is well enough for you to
visit
1) Keep the information to yourself
A manager is reviewing the nurses’s notes in a community patient’s health care record. She finds the following entry. “ Patient is difficult to care for, refuses advice for improving appetite”. Which of the following suggestions should the manager give to the community health nurse who entered the note?
1) Avoid rushing when charting an entry
2) Use correction fluid to remove the entry
3) Draw a single line through the statement and initial it
4) Enter only objective and factual information about the
patient
4) Enter only objective and factual information about the
patient
A patient tells the nurse “ I have stomach cramps and feel nauseated”. This is an example of which type of data?
1) objective 2) Historical 3) Subjective 4) Assessment
3)Subjective
During your visit to a patient’s home, your patient says, “ I do no know what is join on; I cannot get an explanation from my doctor about the results of my test. I want something done about this”. Which of the following is the most appropriate documentation of the patient’s emotional status?
1) The patient has a defiant attitude and demands his
test results
2) The patient appears to be upset with his physician
about his test results
3) The patient is demanding and complains frequently
4) The patient states he is frustrated by the lack of
information about his test results.
4) The patient states he is frustrated by the lack of
information about his test results.
Patients frequently request copies of their health care records. Which of the following statements is true regarding patient access to health care records?
1) Patients have the right to read those records
2) Patients are not allowed to read those records
3) Only the health care workers have access to the
records
4) Only the families may read the records
1) Patients have the right to read those records
Accurate entries are an important characteristic of good documentation. Which of the following charting entries is most accurately written?
1) Patient ambulated in hall with assistance, exercise well tolerated
2) Patient ambulated 15m up and down hall, exercise well tolerated
3) Patient ambulated 15 m up and down hall with assistance from nurse
4) Patient ambulated 15 m with assistance from nurse. Pre-exercise HR 88, post exercise HR 94
4) Patient ambulated 15 m with assistance from nurse. Pre-exercise HR 88, post exercise HR 94
What is the purpose of acuity records?
1) to guide all nursing care 2) to document to patient admission 3) to determine hours of care needed 4) to establish guidelines for patient care
3) to determine hours of care needed
