WEEK 3 Flashcards
Electronic health records (EHR)
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
Health record
an individualized collection of health information and data about a client’s health
Can clients track their own health using EHR?
yes, like MyChart
What do client’s health records include?
demographics, vital signs, medical history, medications, allergies and immunizations, as well as other information
When did the first utilization of EHRs emerge?
in the 1960s
In what year did the IOM recommend the adoption of EHRs nationwide for safer health care?
1997
What are some advantages of EHRs?
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
What are the documentation methods?
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)
Source-Oriented Medical Records
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.
Why do many institution no longer use the source-oriented medical record?
can limit sharing of information among the members of the interdisciplinary team and lead to fragmented care.
Problem-Oriented Medical Records
Developed by Lawrence L. Weed
Used to create a comprehensive and organized approach among all members of the interdisciplinary team.
What are the four components of the Problem-Oriented Medical Records?
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
SOAP documentation
This type of documentation is widely used and allows clinicians to communicate in a systematic and organized way
Component of POMR
SOAP: S
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
What is an example of S in SOAP?
Client states “I noticed I’m a bit short of breath when I walked in the hallway”
SOAP: O
OBJECTIVE
clinical impressions recorded in this section are based on what the nurse observes or measures
includes: vitals signs and physical assessment findings
What is an example of O in SOAP?
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.
SOAP: A
ASSESSMENT
provided an analysis of the combined subjective AND objective data that were collected
What is an example of A in SOAP?
Client’s respiratory status is altered with productive cough and increase dyspnea
SOAP: P
PLAN
this section details interventions the nurse plans to implement
What is an example of P in SOAP?
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.
PIE Model
focuses on the client’s:
Problems
Interventions
Evaluations
Focus Charting
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).
Charting by Exception
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.
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
FACT Charting
acronym provides a guide for accurate documentation including elements that promote consistency and complete documentation
Factual, Accurate, Complete, and Timely
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
What is an example of F in FACT?
Client’s head is round, symmetrical, and normocephalic. No nodules or depressions present when palpated
FACT: A
should establish accuracy by including exact descriptions and measurements.
This provides concrete data for comparing a client’s condition over time.
What is an example of A in FACT?
Client voided 420 mL clear, yellow urine at 0900.
FACT: C
must be complete; it must contain the what, when, where, why, and how. All information provided must be nonbiased.
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.
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.
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
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
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
When is it acceptable to repeat back a verbal prescription without writing it down first?
in a sterile environment
What prescriptions should you not accept verbal prescriptions?
chemotherapeutic medications,
UNLESS the directive is to withhold or stop the medication.
What year did HIPPA take effect?
2003
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”
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
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.
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
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.
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
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
What are the steps in the nursing process?
Assessment
Analysis
Planning
Implementation
Evaluation
Nursing Process: Assessment
gather data from the client through interview, physical exam, and observation to make judgments
Nursing Process: Analysis
use clinical judgment to evaluate data collected to formulate the client’s problems, including actual and potential problems
Nursing Process: Planning
Use problem-solving and decision-making skills to prioritize outcomes and goals, and develop interventions to meet those goals
Nursing Process: Implementation
Carry out the interventions that have been established, use clinical judgments to monitor the client’s progress towards achieving their goals
Nursing Process: Evaluation
Assess the effectiveness and achievability of the goals and the need for interventions to be adjusted
What are some components of critical thinking?
Contextual awareness
Analyzing assumptions
Exploring alternatives
Using credible sources
Reflecting and deciding
Contextual awareness
understanding the status of the client and the events that have led to their interaction with the health care team.
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.
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.
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.
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.
Is analyzing assumptions part of critical thinking process for the PN?
no
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
Is percussion usually preformed by a licensed nurse?
no, percussion is preformed by an advanced provider
Which of the following tools and techniques are used to perform assessment on the chest?
auscultate, stethoscope, inspect
Which of the following tools and techniques are used to perform assessment on the abdomen?
palpate, auscultate, stethoscope, inspect, tape measure
Which of the following techniques are used to preform assessment on the eyes?
penlight, inspect, palpate
Which of the following tools and techniques are used to perform assessment on the feet?
doppler, palpate, inspect
What tools are used for ascultation?
stethoscope and doppler
What do you base off of physical assessment?
plan of care
What is the role of PNs in physical assessment?
PNs can collect data, but they cannot analyze it
Nursing Process Steps
Assessment
(Nursing) Diagnosis
Planning
Implementation
Evaluation
Clinical Judgment Process
imbedded in nursing process
Recognize cues
Analyze cues
Prioritize hypothesis
Generate solutions
Take action
Evaluate outcomes
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)
Types of Assessement
Patient-centered interview (nursing history) (on admission)
Periodic assessments (ongoing contact with clients)
The types of assessments can also be what?
comprehensive: head-to-toe
focused: assessment of problem/problem area (most common in ER clients)
Critical Thinking in Assessment
Knowledge Case
Environment
Experience
Standards
Attitudes
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
Critical Thinking in Assessment: Environment
Time pressure
setting
task complexity
interruptions
Critical Thinking in Assessment: Experience
Personal
clinical experience in assessment, physical examination, knowing what to examine
skill competence (experience with skills)
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)
Critical Thinking in Assessment: Attitudes
Perseverance
Curiosity
Confidence
Discipline
Responsibility
EXAM QUESTION!
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!
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
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
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!
Environment in Assessment
setting
time pressure
task complexity
interruptions
EXAM QUESTION!
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
The Nursing Health History Format
cultural considerations
professionalism in history taking
components of the nursing health history (look at seperate flashcard)
data documentation
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
What is a priority in post-op patient?
need to move!
EXAM QUESTION!
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)
What do you use diaphragm/bell with on a stethoscope for?
diaphragm- high-pitch sounds (bowel, breathing)
bell- low-pitch sounds (heart murmurs, bruits)
General Survey
Physical appearance
body structure
mobility
behavior
vital signs
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
Dorsal surface is most sensitive to what?
temperature
The palmar surface and base of fingers are most sensitive to what?
vibration
fingertips are sensitive to what?
pulsation
positive
texture
turgor
size
consistency
