Purposes of Medical Records - Documenting and Reporting Flashcards
A valuable source of client data for all members of the health care team. Data entered into it facilitates interdisciplinary communication and care planning; provides a legal record of care provided; facilitates funding and resource management; and allows for auditing, monitoring, and evaluation of care provided.
Medical record
This should be the most current and accurate source of information about a patient’s health care status.
Medical record
In the medical record, as a nurse, always communicate the manner in which you conduct the ___ ___ with a patient.
nursing process
The admitting nursing history and physical assessment are comprehensive and provide baseline data about the patient’s health status on ___ to the facility. These data usually include biographical information (e.g., age and marital status), method of admission, reason for admission, a brief medical-surgical history (e.g., previous surgeries or illnesses), allergies, current medication (prescribed and over-the-counter), the patient’s perceptions about illness or hospitalization, and a review of health risk factors. Results of a physical assessment of all body systems are either documented in the ___ ___ or included on a separate form.
admission / nursing history
Provides data that you use to identify and support nursing diagnoses, establish expected outcomes of care, and plan and evaluate interventions.
Medical record
Information from the ___ ___ adds to your observations and assessment. You do not need to collect information that is already available. If you have reason to believe that the information is inaccurate, information should be verified and appropriate changes made to the patient’s ___ ___.
Medical / record / medical / record
Accurate documentation is one of the best defences against ___ claims associated with nursing care.
legal
From a ___ perspective, the purpose of documentation is to provide proof of health care provided.
legal
Should accurately and fully reflect patient care as well as the patient’s response to that care.
Documentation
To limit nursing liability, as the nurse you must clearly document that individualized, goal-directed nursing care, based on the nursing assessment, was provided to a patient and that you continue to monitor for, document, and report deter___.
deter-ioration
The record must describe ex___ what happened to a patient.
ex-actly
Charting should be performed ___ after care is provided.
immediately
True or false: nursing care may have been excellent, but in a court of law, care not documented is care not provided.
True
In the healthcare ___, you need to indicate all assessments, interventions, patient responses, instructions, and referrals.
record
It is important to complete all documentation on appropriate ___ and to be sure that patient-i___information (patient’s name and i___ number) is on every page of documentation.
forms / i-dentifying x2
Eight common charting mistakes that can result in malpractice: (1) failing to record pertinent health or drug information, (2) failing to record nursing ___, (3) failing to record that ___ have been given, (4) recording on the ___ chart, (5) failing to document a discontinued medication, (6) failing to record drug reactions or ___ in the patient’s condition, (7) transcribing orders ___ or transcribing improper orders, and (8) writing illegible or ___ records.
actions
medications
wrong
changes
improperly
incomplete
Enter only ___ and factual descriptions of a patient’s behaviour or the actions of another health care provider. Quote all patient statements.
Objective
Avoid ___ to complete documentation; be sure that information is accurate and c___.
rushing / c-omplete
Errors in recording can lead to errors in treatment or may imply an attempt to mislead or hide ___.
evidence
Be certain entry is factual and thorough. A person reading your documentation needs to be able to determine that a patient received ad___ care.
ad-equate
Record must be accurate, f___, and objective.
f-actual
Record ___ facts.
all
Document as soon after the event as possible to ensure a___.
a-ccuracy
If an order is questioned, record that ___ was sought.
clarification
True or false: if you perform an order known to be incorrect, you are just as liable for prosecution as the prescriber is.
True
Do not record, “physician made error”; instead, chart that “Dr. Wong was called to ___ order for analgesic.” Include the date and time of phone call, whom you spoke with, and the outcome.
clarify
Document only for ___.
yourself
You are ___ for information you enter into a patient’s record.
accountable
___ enter documentation for someone else. Check agency policy for circumstances when a ___ party may document for another nurse (e.g., designated recorder for emergency situations).
Never / third
Avoid using gen___, empty phrases such as “status unchanged” or “had good day.”
gen-eralized
Use complete, concise descriptions of assessments and care so that documentation is ___ and factual.
objective
Begin each entry with the ___ and ___ and end with your signature and cr___.
date / time / cr-edentials
Avoid “pre___” (documenting an entry before performing a treatment or an assessment or before giving a medication).
pre-charting
Document during or ___ after giving care or after administering a medication.
immediately
Once logged into a computer, do not leave computer screen un___. Log out when you ___ the computer. Make sure the computer screen is not accessible for ___ viewing.
un-attended / leave / public
Draw a ___ line through error; write “___,” above it, and sign your name or ___ and ___ it. Then record note correctly.
single / error / initials / date
Chart consecutively, line by line; if space is left, draw a ___ ___tally through it and place your signature and cr___ at the end.
line / horizon-tally / cr-edentials
Record all entries legibly and in ___ ink. Do ___ use felt-tip pens or erasable ink.
black / NOT
___ use pencil to document in a written clinical record.
NEVER
Never ___ entries or use correction fluid.
erase
To indicate an error in written documentation, place a single ___ through the inaccurate information and write your s___ with credentials at the end of the text that has been crossed out.
line / s-ignature
Shows how healthcare agencies have used their financial resources.
Record
A regular review of information in patient ___ helps the nurse evaluate the quality and appropriateness of care. This ___ may be either a review of care received by discharged patients or an evaluation of care currently being given. Most Canadian health care agencies have continuous quality improvement programs and teams to ___ and improve the delivery of health care services. These teams often contain members from across the organization, and they normally perform the self-assessment requirements of A___ Canada.
record / audit / monitor / A-ccreditation
Nurses or interdisciplinary members of a committee ___ or review records throughout the year to determine the degree to which quality improvement standards are met. Deficiencies are explained to the nursing staff so that corrections in policy or practice can be made.
monitor
Used for communication in care, funding and resource management, auditing and monitoring, research, and education.
Medical records
Statistical data relating to the frequency of clinical disorders, complications, use of specific medical and nursing therapies, recovery from illness, and deaths can be gathered from patient ___. For example, as part of a quality improvement program for patients receiving intravenous therapy, a nurse manager reviews patients’ ___ to investigate the incidence of infection in patients with a specific type of intravenous catheter.
records x2
Some data collection activities may be part of the quality ___ practices at an agency, whereas other activities may be actual clinical research studies.
improvement
One way to learn the nature of an illness and an individual’s response to it is to read a patient care ___. A patient’s ___ contains a variety of information, including diagnoses, signs and symptoms of disease, successful and unsuccessful therapies, diagnostic findings, and patient behaviours.
record x2
No two patients have identical ___, but in the course of clinical training nursing and other health care students review ___ of patients who have similar health problems to identify patterns of information and anticipate the type of care required for a patient.
records x2
