Purposes of Medical Records - Documenting and Reporting

Question 1

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.

Answer 1

Medical record

Question 2

This should be the most current and accurate source of information about a patient’s health care status.

Answer 2

Medical record

Question 3

In the medical record, as a nurse, always communicate the manner in which you conduct the ___ ___ with a patient.

Answer 3

nursing process

Question 4

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.

Answer 4

admission / nursing history

Question 5

Provides data that you use to identify and support nursing diagnoses, establish expected outcomes of care, and plan and evaluate interventions.

Answer 5

Medical record

Question 6

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 ___ ___.

Answer 6

Medical / record / medical / record

Question 7

Accurate documentation is one of the best defences against ___ claims associated with nursing care.

Answer 7

legal

Question 8

From a ___ perspective, the purpose of documentation is to provide proof of health care provided.

Answer 8

legal

Question 9

Should accurately and fully reflect patient care as well as the patient’s response to that care.

Answer 9

Documentation

Question 10

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___.

Answer 10

deter-ioration

Question 11

The record must describe ex___ what happened to a patient.

Answer 11

ex-actly

Question 12

Charting should be performed ___ after care is provided.

Answer 12

immediately

Question 13

True or false: nursing care may have been excellent, but in a court of law, care not documented is care not provided.

Answer 13

True

Question 14

In the healthcare ___, you need to indicate all assessments, interventions, patient responses, instructions, and referrals.

Answer 14

record

Question 15

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.

Answer 15

forms / i-dentifying x2

Question 16

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.

Answer 16

actions

medications

wrong

changes

improperly

incomplete

Question 17

Enter only ___ and factual descriptions of a patient’s behaviour or the actions of another health care provider. Quote all patient statements.

Answer 17

Objective

Question 18

Avoid ___ to complete documentation; be sure that information is accurate and c___.

Answer 18

rushing / c-omplete

Question 19

Errors in recording can lead to errors in treatment or may imply an attempt to mislead or hide ___.

Answer 19

evidence

Question 20

Be certain entry is factual and thorough. A person reading your documentation needs to be able to determine that a patient received ad___ care.

Answer 20

ad-equate

Question 21

Record must be accurate, f___, and objective.

Answer 21

f-actual

Question 22

Record ___ facts.

Answer 22

all

Question 23

Document as soon after the event as possible to ensure a___.

Answer 23

a-ccuracy

Question 24

If an order is questioned, record that ___ was sought.

Answer 24

clarification

Question 25

True or false: if you perform an order known to be incorrect, you are just as liable for prosecution as the prescriber is.

Answer 25

True

Question 26

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.

Answer 26

clarify

Question 27

Document only for ___.

Answer 27

yourself

Question 28

You are ___ for information you enter into a patient’s record.

Answer 28

accountable

Question 29

___ 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).

Answer 29

Never / third

Question 30

Avoid using gen___, empty phrases such as “status unchanged” or “had good day.”

Answer 30

gen-eralized

Question 31

Use complete, concise descriptions of assessments and care so that documentation is ___ and factual.

Answer 31

objective

Question 32

Begin each entry with the ___ and ___ and end with your signature and cr___.

Answer 32

date / time / cr-edentials

Question 33

Avoid “pre___” (documenting an entry before performing a treatment or an assessment or before giving a medication).

Answer 33

pre-charting

Question 34

Document during or ___ after giving care or after administering a medication.

Answer 34

immediately

Question 35

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.

Answer 35

un-attended / leave / public

Question 36

Draw a ___ line through error; write “___,” above it, and sign your name or ___ and ___ it. Then record note correctly.

Answer 36

single / error / initials / date

Question 37

Chart consecutively, line by line; if space is left, draw a ___ ___tally through it and place your signature and cr___ at the end.

Answer 37

line / horizon-tally / cr-edentials

Question 38

Record all entries legibly and in ___ ink. Do ___ use felt-tip pens or erasable ink.

Answer 38

black / NOT

Question 39

___ use pencil to document in a written clinical record.

Answer 39

NEVER

Question 40

Never ___ entries or use correction fluid.

Answer 40

erase

Question 41

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.

Answer 41

line / s-ignature

Question 42

Shows how healthcare agencies have used their financial resources.

Answer 42

Record

Question 43

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.

Answer 43

record / audit / monitor / A-ccreditation

Question 44

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.

Answer 44

monitor

Question 45

Used for communication in care, funding and resource management, auditing and monitoring, research, and education.

Answer 45

Medical records

Question 46

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.

Answer 46

records x2

Question 47

Some data collection activities may be part of the quality ___ practices at an agency, whereas other activities may be actual clinical research studies.

Answer 47

improvement

Question 48

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.

Answer 48

record x2

Question 49

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.

Answer 49

records x2