Week 10: Professional Nursing Care (Documentation/Communication) Flashcards
Definition: Abbreviations
A shortened word or phrase
Definition: EMR
Electronic medical records
Definition: Documentation
The recording of things just as they happened on paper, audio, or EMR, must be accurate and comprehensive and must reflect standards of nursing practice; Ethical, legal, medical, and agency guidelines influence documentation
Definition: SOAP
Subjective, Objective, Assessment, Plan
Definition: Subjective data
What the patient feels that cannot be actually measured
Definition: PIE
Problem, Intervention, Evaluation
Definition: Health informatics
An interdisciplinary field that focuses on the effective use of biomedical data, information, and knowledge for scientific inquiry, problem-solving, and decision-making to improve human health
It involves developing, designing, and utilizing information technologies and systems to manage and optimize health information.
Definition: Objective data
Information that can be measured or is visible to everyone such as vital signs
Definition: Focused charting
A method of organizing patient information in medical records using a structured format with Focus, Data, Action, and Response elements
It allows healthcare professionals to document specific patient concerns, data collected, interventions taken, and the patient’s response to those interventions
Definition: DAR
Data, Action, Response
Definition: Charting by exception
A documentation method that records only significant or unexpected patient findings
It’s also known as variance charting; saves time, improve clarity
Definition: SBAR
Stands for ‘Situation, Background, Assessment, Recommendation’ and was originally developed in the military context to create a reliable consistent process to facilitate concise, clear, focused communication.
Definition: Telepractice
Health practices that provide health care to clients over geographical distances (ex. phone calls, two-way video such as Zoom, email, online chats)
Definition: Nursing informatics
An ever-evolving field of study in which information, technology and communication is integrated into nursing practice, goal is to improve patient care
Definition: EHR
Electronic health records
What are CNO documentation standards?
Communication
Accountability
Security
Why is communication important?
It provides an accurate, clear and comprehensive picture
of the patient’s needs,
nurse’s interventions
and patient outcomes.
What are some indicators of CNO documentation standards for Communication?
Objective and subjective data
Full signature/initials
Legible and in permanent ink
What are some indicators of CNO documentation standards for Accountability?
- Timely documentation following care/event
- In chronological order
- Document date and time
- Correcting errors while ensuring that the original
information remains visible/retrievable
What are some indicators of CNO documentation standards for Security?
- Ensuring relevant info is captured
- Maintaining confidentiality of client information
- Facilitating the rights of the client or substitute decision-
maker to access, and obtain a copy - Advocating for clear documentation policies
What are some guidelines for documentation?
Documentation should be factual, complete, and accurate
Is it okay to pre-chart?
NO
What type of clock is used for documentation?
Military/24 hour clock
What is the issue with trailing zeros?
If the period is too small it may not be seen and the wrong dose could be administered
What is Subjective data?
What the patient says; how they describe their pain, diet, sleep, exercise, ADLs, etc.
What is Objective data?
Observations made by nurses, vital signs, physical assessment findings
What does SOAP stand for?
Subjective
Objective
Assessment
Plan
What does PIE stand for?
Problem
Intervention
Evaluation
What does DAR stand for?
Data
Action
Response
What are verbal orders?
Orders (often written “VO”) given to an RN from a provider when they are standing in close proximity to each other.
What are telephone orders?
Orders (often written “TO”) therapeutic orders given over the phone to an RN
When are telephone and verbal orders given?
Usually at night or during emergencies
Are we permitted as students to take VOs or TOs?
NOOOOOOO
What is Information and Knowledge Management?
Using relevant information and knowledge to support the delivery of evidence informed patient care
What is Using relevant information and knowledge to support the delivery of
evidence informed patient care?
Uses and develops ICTs in accordance with professional and regulatory standards and workplace policies
What is Information and Communication Technologies?
Uses ICTs in the delivery of patient/client care
What is SBAR?
SBAR is an easy to use, structured form of communication that enables
information to be transferred accurately between individuals and provide information quickly, and clearly
What does SBAR stand for?
Situation
Background
Assessment
Recommendation
What is the Transfer of Accountability (TOA)?
At the end of each shift nurses report information about their assigned patients to the
nurses working on the next shift; This report can be orally in person, an audiotape recording, a summary report sheet, or at the patient’s bedside and needs to be current, objective, and concise
