UNIT 3: Documentation; Introduction to medical terminology

Question 1

Documentation:

Answer 1

The process of documenting nursing info about nursing care in health records.

Question 2

Uses and purposes of Medical Records:

Answer 2

Communication/Care Planning
Legal Documentation
Funding/Resource Management
Auditing & Monitoring
Research
Education

Question 3

Types of Records:

Answer 3

Electronic health record
Source-oriented record
Problem-oriented record

Question 4

Ways to document nursing care:

Answer 4

Narrative
SOAP[IE]
PIE
Focus Charting (DAR)
Chart by Exception
Case Management

Question 5

Electronic Health Record (EHR):

Answer 5

Refers to a longitudinal (lifetime) record of all healthcare encounters for an individual.

Question 6

Electronic Medical Record (EMR):

Answer 6

Refers to the legal record that describes a single encounter/visit by a patient to a hospital or out-patient healthcare setting.
(the source of data for the EHR)

Question 7

Problem-oriented Healthcare/Medical Records (POMR):

Answer 7

A system for organizing documentation that places the primary focus on the Pts individual problems. POMR has 4 major sections:
- Database
- Problem List
- Care Plan
- Progress Notes

Question 8

POMR: Database

Answer 8

Contains all available assessment info pertaining to the patient. the database provides the foundation for identifying Pt problems and planning care.
- Includes: medical history; physical assessment; nursing admission history; ongoing assessment; lab reports; + test results

Question 9

POMR: Problem List

Answer 9

Includes a patients physiological, psychological, social, cultural, spiritual, developmental, and environmental needs.

Question 10

POMR: Care Plan

Answer 10

Team members from each discipline that are involved in a Pt’s care develop a care plan for each problem (ADPIE)

Question 11

POMR: Progress Notes

Answer 11

Where healthcare members monitor and record a Pt’s progress. There are many formats of progress notes:
1) SOAP
2) SOAPIE
3) PIE
4) DAR

Question 12

Source-oriented Record:

Answer 12

A traditional “chart”
Where the patients chart is organized so that each discipline has their own section to record data. There are many components/sections of a source record (9 main ones)

Question 13

9 Main Sections/Components of a Source Record:

Answer 13

Admission sheet
Nurse’s admission sheet
Medical history & exam
Progress notes
Discharge summary
Order sheet
Graphic/flow chart
Medication administration record (MAR)
Healthcare disciplines records

Question 14

Ways to document nursing care: Narrative Charting

Answer 14

The method traditionally used to record patient assessment and the nursing care provided. This method documents info in a simple, story-like format

Question 15

Ways to document nursing care: SOAP

Answer 15

Can only really be used for a singular condition and stands for:
Subjective-Objective-Assessment-Plan

Question 16

Ways to document nursing care: SOAPIE

Answer 16

Same as soap but with intervention and evaluation added on:
Subjective-Objective-Assessment-Plan-Intervention-Evaluation

Question 17

Ways to document nursing care: PIE

Answer 17

Was created with nurses and nursing care in mind. PIE stands for:
Problem-Intervention-Evaluation
*There is no assessment done in PIE, it is done separately.

Question 18

Ways to document nursing care: DAR (Focus Charting)

Answer 18

DAR, a.k.a. Focus Charting is the most patient-centred form of documentation. It is based on the patient’s concerns. DAR stands for:
Data (objective & subjective)-Action (interventions)-Response (evaluation/Pt’s response)

Question 19

Ways to document nursing care: Charting by Exception (CBE)

Answer 19

Based on the idea that a Pt meets all standards unless otherwise documented. this system incorporates standards of care, evidence-informed interventions, and clearly defined criteria for/of “normal” findings

Question 20

Within Defined Limits (WDL)/Within Normal Limits (WNL):

Answer 20

Pre-defined definitions or statements that consists of written criteria for a “normal” assessment for each body system.

Question 21

Ways to document nursing care: Case Management and use of Critical Pathways

Answer 21

• The case management model incorporates an interdisciplinary approach to documenting Pt care.
  
  • Critical pathways are standardized plans of care for a specific disease/condition (there can be variance)

Question 22

Variance:

Answer 22

When the activities on the critical pathway are not completed as predicted or patient does not meet the expected outcomes.

Question 23

Common Record Keeping forms: (7 types)

Answer 23

1) Admission Database
2) Standardized Care Plan
3) Kardex (temporary record)
4) Flowsheets/Graphic Record
5) Progress Notes
6) Discharge Summary
7) Incident/Work Safety Reports

Question 24

Common Record Keeping forms: Admission Database

Answer 24

Completed when a Pt is admitted to a nursing care unit. Data on history forms provide baselines that can be compared with changes in the Pt’s condition

Question 25

Common Record Keeping forms: Standardized Care Plan

Answer 25

Plans based on the institutions of nursing practice that are pre-printed, established guidelines that are used to care for Pt’s who have similar health problems

Question 26

Common Record Keeping forms: Kardex (temporary record)

Answer 26

Provides basic summative info and can be continually updated. it provides the nurse with a list of orders, treatments, + diagnostic testing.

Question 27

Info commonly found on the Pt care summary or Kardex includes:

Answer 27

Basic demographic data
Hospital ID#
Medical + Surgical history
Physicians name
Primary Medical Diagnosis
Current Prescriptions
Nursing care plan
Nursing orders
Allergies
Contact Info
Emergency Code Status

Question 28

Common Record Keeping forms: Flowsheets/Graphic Records

Answer 28

Used to document physiological data and routine care. These allow the nurse to quickly & easily enter assessment data a/b a Pt, such as vital signs, admission + daily weights.

Question 29

Common Record Keeping forms: Progress Notes

Answer 29

Specific to nurses
Where nurses write their narrative documentation.

Question 30

Common Record Keeping forms: Discharge Summary

Answer 30

Helps ensure a Pt leaves the hospital in a timely manner with the necessary resources in place. Discharge planning normally begins at admission.

Question 31

Common Record Keeping forms: Incident/Work Safety Reports

Answer 31

For unusual occurrences for:
- Involved in or witness
- Near-miss/Errors
- No Blame (don’t ever place blame on others)

Question 37

The 6 Characteristics/Guidelines of Quality Documenting:

Answer 37

Factual
Accurate
Complete
Current
Organized
Compliant with Standards
Timely
Sign ALL Entries

Question 38

3 Types of Medical Terms:

Answer 38

1) Latin and Greek Word Parts
2) Eponyms
3) Modern English Words

Question 39

Parts of Latin + Greek Based Words:

Answer 39

Word Roots
Suffixes
Prefixes
Combining Vowels

Question 40

Eponyms:

Answer 40

Terms based on a person’s name

Question 41

Word Roots:

Answer 41

Gives the essential meaning of the term. Normally (but not always) refers to a body structure, organ, or system.

Question 42

Suffixes:

Answer 42

Found at the end of the medical term and provides info on conditions, diseases, surgical + diagnostic procedures.

Question 43

Prefixes:

Answer 43

Found at the beginning of the medical term and provides info on abnormal conditions, #s, positions, and times.

Question 44

Combining Vowels:

Answer 44

Used to connect words and make medical terms easier to say by placing a vowel between a root and a suffix or between 2 word roots (usually an o)