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WEEK 3 Flashcards

1
Q

Electronic health records (EHR)

A

A computerized, real-time form of a client’s paper chart that can be shared between members of the interprofessional team; includes information such as the medical history, diagnosis, allergies, and diagnostic testing results.

They are also important for financial reimbursement

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2
Q

Health record

A

an individualized collection of health information and data about a client’s health

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3
Q

Can clients track their own health using EHR?

A

yes, like MyChart

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4
Q

What do client’s health records include?

A

demographics, vital signs, medical history, medications, allergies and immunizations, as well as other information

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5
Q

When did the first utilization of EHRs emerge?

A

in the 1960s

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6
Q

In what year did the IOM recommend the adoption of EHRs nationwide for safer health care?

A

1997

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7
Q

What are some advantages of EHRs?

A

allow providers to follow a client’s care from one facility to another, with information, including a complete medical history, being available instantaneously, enhance communication, medical and prescription errors are reduced, more reliable coding and billing can occur, improve client care and provide for better health outcomes

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8
Q

What are the documentation methods?

A

Source-oriented medical records

Problem-oriented medical records

Subjective, objective, assessment, and plan charting (SOAP notes)

Problem–intervention–evaluation charting (PIE model)

Focus charting

Charting by exception (CBE)

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9
Q

Source-Oriented Medical Records

A

traditional format for documenting within a medical record for all disciplines.

It is usually divided into specific sections such as history and physical examination, progress notes, nurses’ notes, laboratory reports, and diagnostic testing.

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10
Q

Why do many institution no longer use the source-oriented medical record?

A

can limit sharing of information among the members of the interdisciplinary team and lead to fragmented care.

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11
Q

Problem-Oriented Medical Records

A

Developed by Lawrence L. Weed

Used to create a comprehensive and organized approach among all members of the interdisciplinary team.

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12
Q

What are the four components of the Problem-Oriented Medical Records?

A

A database in which assessment data are documented

A problem list that lists the client’s problem chronologically

An initial plan that outlines goals, expected outcomes, and further data needed, if necessary

Progress notes using the SOAP (subjective, objective, assessment, plan) format

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13
Q

SOAP documentation

A

This type of documentation is widely used and allows clinicians to communicate in a systematic and organized way

Component of POMR

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14
Q

SOAP: S

A

SUBJECTIVE

contains information from the client.
This information can include the client’s feelings or views

collected from the client or sometimes a caregiver or family member

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15
Q

What is an example of S in SOAP?

A

Client states “I noticed I’m a bit short of breath when I walked in the hallway”

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16
Q

SOAP: O

A

OBJECTIVE

clinical impressions recorded in this section are based on what the nurse observes or measures

includes: vitals signs and physical assessment findings

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17
Q

What is an example of O in SOAP?

A

Temperature: 99.4° F (37.4° C); Heart rate 88/min; Respiration rate 20/min; Blood pressure 138/88 mmHg; SpO2 93% on room air while at rest.

Respirations unlabored at rest but becomes slightly dyspneic while speaking. Color is pale. Lung sounds diminished in the bases bilaterally. Frequent cough productive for thick green sputum.

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18
Q

SOAP: A

A

ASSESSMENT

provided an analysis of the combined subjective AND objective data that were collected

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19
Q

What is an example of A in SOAP?

A

Client’s respiratory status is altered with productive cough and increase dyspnea

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20
Q

SOAP: P

A

PLAN

this section details interventions the nurse plans to implement

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21
Q

What is an example of P in SOAP?

A

Elevate HOB. Notify provider of change in client status. Monitor client’s respiratory status every hour. Encourage coughing and deep breathing. Encourage increased fluid intake.

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22
Q

PIE Model

A

focuses on the client’s:

Problems
Interventions
Evaluations

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23
Q

Focus Charting

A

documents a client’s specific health care problem by focusing on the nursing diagnosis as well as changes in the client’s condition, events, and concerns.

The three items that must be documented when using the focused charting method are data, action, and response (DAR).

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24
Q

Charting by Exception

A

focuses on documenting only unexpected or unusual findings based on standardized protocols.

involves the use of a physical assessment flowsheet with normal or expected findings

Be aware that CBE is not the most effective form of documentation, as it creates the assumption that the client’s care was routine and followed all standards.

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25
What are the advantages of electronic documentation?
Real-time access to client records by all members of the interdisciplinary team Built-in clinical alerts that contribute to the reduction and prevention of medical errors and duplicate tests Increased coordination of care Elimination of illegible records Client portals that allow the client to interact with providers
26
FACT Charting
acronym provides a guide for accurate documentation including elements that promote consistency and complete documentation Factual, Accurate, Complete, and Timely
27
FACT: F
Factual should contain concrete, objective, and descriptive information; objective data is obtained by direct observation and measurement: this is what the nurse sees, hears, smells, and feels
28
What is an example of F in FACT?
Client's head is round, symmetrical, and normocephalic. No nodules or depressions present when palpated
29
FACT: A
should establish accuracy by including exact descriptions and measurements. This provides concrete data for comparing a client’s condition over time.
30
What is an example of A in FACT?
Client voided 420 mL clear, yellow urine at 0900.
31
FACT: C
must be complete; it must contain the what, when, where, why, and how. All information provided must be nonbiased.
32
What is an example of C in FACT?
JR, RN, administered Colace 100 mg PO (by mouth) at 1000. Client denied any discomfort at the time of administration.
33
FACT: T
documentation should be put in chronological order. This gives a clear understanding of what has happened. Refrain from charting on clients until the end of the shift.
34
What is an example of T in FACT?
Blood glucose was obtained at 0732. BS was 127. Per sliding scale, the client received 2 units of Novolog subcutaneously in RUQ of abdomen at 0745. Breakfast tray at bedside
35
What are some acceptable abbreviations?
ABD Abdomen a.c. or ac Before meals Ad lib At liberty (client can move around freely) BID or b.i.d. Twice a day BK Below the knee BP Blood pressure cath Catheter CBC Complete blood count c/o complains of CPR Cardiopulmonary resuscitation C & S Culture and sensitivity CXR Chest x-ray DNR Do not resuscitate DX Diagnosis FBS Fasting blood sugar GI Gastrointestinal gtt Drop H&H Hemoglobin and hematocrit HOB Head of bed hr Hour Hx History ICU Intensive care unit I&O Input and output IV Intravenous LLE Left lower extremity LMP Last menstrual period LOC Level of consciousness LUE Left upper extremity MI Myocardial infarction (heart attack) MRSA Methicillin-resistant Staphylococcus aureus NG Nasogastric NKA No known allergies NKDA No known drug allergies NPO Nothing by mouth N&V, N/V Nausea and vomiting O2 Oxygen OOB Out of bed per Through or by PO By mouth PRN As needed q Every r/o Rule out Rx Prescription Stat At once, immediately TID Three times a day Tx Treatment UA Urinalysis Wt Weight
36
What to do when taking verbal prescription?
write it down in the client's record as it is received so that is can be read back The only time a prescription does not need to be written down immediately is when there is an emergency or in a sterile environment. In these situations, the nurse should repeat back the prescription prior to its implementation
37
When is it acceptable to repeat back a verbal prescription without writing it down first?
in a sterile environment
38
What prescriptions should you not accept verbal prescriptions?
chemotherapeutic medications, UNLESS the directive is to withhold or stop the medication.
39
What year did HIPPA take effect?
2003
40
What are some unacceptable abbreviations?
IU (International Unit) Mistaken for IV (intravenous) or the number 10 (ten) Write “International Unit” MS MSO4 and MgSO4 Mistaken for morphine sulfate or magnesium sulfate Often mistaken for each other Write “morphine sulfate” Write “magnesium sulfate” Per os Mistaken for “left eye” Write “PO,” “by mouth,” or “orally” qd, q.d., Q.D., or QD Mistaken for q.i.d. Write “daily” qhs Mistaken as “qhr” or every hour Write “nightly” qod, q.o.d., Q.O.D., or QOD Mistaken for q.i.d. Write “every other day” SC, SQ, sub q SC mistaken for SL SQ, mistaken for “5 every” The “q” in SQ, sub q mistaken for “every” Write “subcut” or “subcutaneously” TIW or tiw Mistaken for 3 times a day or twice a week Write “three times weekly” Trailing zero (X.0 mg) Lack of leading zero (.X mg) Decimal point is overlooked Write “X mg” Write “0.X mg” U, u (unit) Mistaken for the number 4 (four), cc, or 0 (zero) Write “unit”
41
Are verbal prescription reserved to emergency situations? If so, why?
due to the potential for error in transcription and omission of safety safeguards that are built into computerized provider order entry systems
42
What are some vulnerabilities associated with verbal prescriptions?
the potential to misinterpret spoken language due to dialects or pronunciations; the presence of background interference and reception; confusion of clients with similar names and medications with similar-sounding names; and the provider’s lack of familiarity with the client in question.
43
Health assessment
involves the collection, clinical judgment, and evaluation of data to plan and deliver patient-centered care while accounting for the client's preferences, goals, and needs. Baseline information regarding a client
44
Comprehensive vs. Focus Assessment
Comprehensive- is a full examination of all body systems that is conducted in a systematic way from head to toe Focused- the assessment of either a body system or a body part that is guided by the client’s presenting concern.
45
Nursing actions that play a role in health assessment include...?
the use of skills such as inspection, palpation, auscultation, critical thinking, and therapeutic communication; documentation of findings; collaboration with all the members of the health care team; and collaboration with the client
46
Nursing Process
is a problem-solving approach used in the provision of care to complex clients. standard of nursing incorporated by the American Nurses Association for nurses of all educational levels that provides direction for applying critical thinking
47
What are the steps in the nursing process?
Assessment Analysis Planning Implementation Evaluation
48
Nursing Process: Assessment
gather data from the client through interview, physical exam, and observation to make judgments
49
Nursing Process: Analysis
use clinical judgment to evaluate data collected to formulate the client's problems, including actual and potential problems
50
Nursing Process: Planning
Use problem-solving and decision-making skills to prioritize outcomes and goals, and develop interventions to meet those goals
51
Nursing Process: Implementation
Carry out the interventions that have been established, use clinical judgments to monitor the client’s progress towards achieving their goals
52
Nursing Process: Evaluation
Assess the effectiveness and achievability of the goals and the need for interventions to be adjusted
53
What are some components of critical thinking?
Contextual awareness Analyzing assumptions Exploring alternatives Using credible sources Reflecting and deciding
54
Contextual awareness
understanding the status of the client and the events that have led to their interaction with the health care team.
55
Analyzing assumptions
involves the nurse evaluating the client's clinical situation and using critical thinking to use or modifiy standard approaches to meet the specific health needs and concerns of the client. For example, when providing care to a client who has an open fracture to the lower extremity, the nurse should use critical thinking to analyze whether it would be more beneficial to perform a focused assessment of the injured area or to engage in a standard head-to-toe approach when performing the health assessment.
56
Exploring alternatives
the use of holistic approaches for treating the whole person Each client's health needs are unique and are a culmination of the individual's physical health, lifestyle choices, culture, living environments, and life experiences. Each of these factors needs to be taken into consideration, in a nonjudgemental environment, when providing care for the client.
57
Using credible sources
using facility standards, such as policy and procedure manuals; state and federal health care standards, such as state departments of health and The Joint Commission; and multiple scholarly sources to determine best practices.
58
Reflecting and deciding
The nurse should do some self-reflection, then reflect on the client goals and decide on the interventions with client input. The nurse must be aware of the appropriate methods of communication among team members. Evidence-based care is the priority.
59
Is analyzing assumptions part of critical thinking process for the PN?
no
60
What are some things to avoid while communicating therapeutically?
Using inappropriate plural pronouns (“we”) Assuming the client knows about a health interview or physical Asking personal questions that are not relevant to the situation Giving personal opinions Using automatic responses and false reassurances Relaying disapproval of client statements or health practices
61
Is percussion usually preformed by a licensed nurse?
no, percussion is preformed by an advanced provider
62
Which of the following tools and techniques are used to perform assessment on the chest?
auscultate, stethoscope, inspect
63
Which of the following tools and techniques are used to perform assessment on the abdomen?
palpate, auscultate, stethoscope, inspect, tape measure
64
Which of the following techniques are used to preform assessment on the eyes?
penlight, inspect, palpate
65
Which of the following tools and techniques are used to perform assessment on the feet?
doppler, palpate, inspect
66
What tools are used for ascultation?
stethoscope and doppler
67
What do you base off of physical assessment?
plan of care
68
What is the role of PNs in physical assessment?
PNs can collect data, but they cannot analyze it
69
Nursing Process Steps
Assessment (Nursing) Diagnosis Planning Implementation Evaluation
70
Clinical Judgment Process
imbedded in nursing process Recognize cues Analyze cues Prioritize hypothesis Generate solutions Take action Evaluate outcomes
71
What are the two steps in critical thinking in ASSESSMENT?
collect data from primary (client themselves) and secondary (family/friends, past medical history, lab results, etc) interpretation and validation of data to determine whether more data is needed or the database is complete (our clients lives depend on if we ask enough questions)
72
Types of Assessement
Patient-centered interview (nursing history) (on admission) Periodic assessments (ongoing contact with clients)
73
The types of assessments can also be what?
comprehensive: head-to-toe focused: assessment of problem/problem area (most common in ER clients)
74
Critical Thinking in Assessment
Knowledge Case Environment Experience Standards Attitudes
75
Critical Thinking in Assessment: Knowledge Base
Basic science: anatomy, physiology, microbiology underlying disease process- expected findings normal assessment findings assessment standards nursing theory supporting health and wellness-e.g. growth and development, health promotion communication principles family dynamics
76
Critical Thinking in Assessment: Environment
Time pressure setting task complexity interruptions
77
Critical Thinking in Assessment: Experience
Personal clinical experience in assessment, physical examination, knowing what to examine skill competence (experience with skills)
78
Critical Thinking in Assessment: Standards
ANA Standards and Scope of Nursing Practice Clinical practice guidelines and standards of practice intellectual standards in measurement agency policies and procedures Professional (standards of care, ethical standards)
79
Critical Thinking in Assessment: Attitudes
Perseverance Curiosity Confidence Discipline Responsibility EXAM QUESTION!
80
What is the difference between subjective and objective data?
subjective- what the client tells you, family tells you (pain level, i.e.) objective- what you can see, hear, smell, feel (medical record, lab results, x-rays, would be example of this too) EXAM QUESTION!
81
If a member of the interprofessional teams tells you something about the client, i.e. the client walked this many feet in front of me today, is that subjective or objective?
subjective; that data would objective to that interprofessional team member because they saw it themseleves
82
What are the phases of the assessment interview?
orientation and setting an agenda working phase- collecting assessment data termination phase- bring it to a close
83
Interview Techniques
Observation (what do I see?) Open-ended questions (how do you feel?) Closed-ended questions (did you drive here today?) Leading questions (does that pain make you sick?) ask kinds of questions that would lead them to tell you more about their condition Back channeling Probing- need to find out more EXAM QUESTION!
84
Environment in Assessment
setting time pressure task complexity interruptions EXAM QUESTION!
85
Standards in Assessment
Intellectual standards- guide the manner in which a nurse pursues an assessment Professional standards of practice or clinical guidelines- apply standard criteria when assessing a client + compare the patient's assessment findings with what the standard sets as normal or abnormal
86
The Nursing Health History Format
cultural considerations professionalism in history taking components of the nursing health history (look at seperate flashcard) data documentation
87
Components of the nursing health history?
biographical location (where do they live, male/female, preferred pronouns) chied concern or reason for seeking health care patient expectations present illness or health outcome past health history family history psychological history spiritual health review of systems observation of patient behavior
88
What is a priority in post-op patient?
need to move! EXAM QUESTION!
89
Physical Assessment Techniques
Preparation- client is in good position, in good lighting Inspection- what we see Palpation- what we feel Percussion- tapping on body parts (RNs do not usually or ever do this) Auscultation- what we hear with either stethoscope or doppler (doppler can hear pulse, blood flow, and baby heart rate)
90
What do you use diaphragm/bell with on a stethoscope for?
diaphragm- high-pitch sounds (bowel, breathing) bell- low-pitch sounds (heart murmurs, bruits)
91
General Survey
Physical appearance body structure mobility behavior vital signs
92
What are some things to do as part of therapeutic communication?
Introduce yourself (name and title) and the varioius parts of the assessment Determine what the client wants you to call them Allow more time for responses in older adults Make sure the client is comfortable (room temp, chair) When possible, start by asking for the health history, preforming general survey, and measuring vital signs to build rapport prior to moving onto more sensitive parts of the examination Reduce environmental noise (TV, radio, visitors talking) to enhance communication and decrease distractions Ensure understanding by obtaining interpretative services for clients who have language or other communication barriers Note the client's nonverbal communication (body language, eye contact, tone of voice, facial expressions, posture, gait, appearance, gestures) Avoid using medical or nursing jargon, giving advice, ignoring feelings, and offering false reassurance
93
Dorsal surface is most sensitive to what?
temperature
94
The palmar surface and base of fingers are most sensitive to what?
vibration
95
fingertips are sensitive to what?
pulsation positive texture turgor size consistency

Fundamentals (20 decks)

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