Week 4 Documentation

Question 1

A nursing action that produces a written account of pertinent patient data, nursing clinical decisions and interventions and patient responses in a health record

Answer 1

Documentation

Question 2

Purpose of Nursing Documentation

Answer 2

• Reflects a client’s perspective.
• Communicates to all health care providers
• Integral component of interprofessional documentation
• Demonstrates the nurse’s commitment to safe, effective and ethical care
• Meets the professional standard regulations

Question 3

A formal, legal document that provides evidence of a client’s care and can be written or computer based

Answer 3

Medical Record

Question 4

Purpose of Medical Records

Answer 4

• Facilitate interdisciplinary communication and care planning
• Provide a legal record of care provided
• Facilitate funding and resource management
• Allow for auditing monitoring and evaluation of care provided
• Serve as sources of research data and as learning resources for nursing and health care education

Question 5

Common Record Keeping Forms

Answer 5

• Admission Nursing History Form
• Flow Sheets and Graphic Records
• Patient Care Summary or Kardex
• Standardized Care Plans
• Discharge Summary Forms
• MAR

Question 6

8 common charting mistakes that can result in malpractice

Answer 6

Failing to record pertinent health or drug information
Failing to record nursing actions
Failing to record that medications have been given
Recording on the wrong chart
Failing to document a discontinued medication
Failing to record drug reactions or changes in the patient’s condition
Transcribing orders improperly or transcribing improper orders
Writing illegible or incomplete records

Question 7

Guidelines for Quality Documentation

Answer 7

Factual
Accurate
Complete
Current
Organized
Compliant with standards

Question 8

An act that specifies that health information custodians should ensure that clients’ personal health information is kept confidential and secure.

Answer 8

PHIPA ACT 2004

Question 9

5 methods of Documentation

Answer 9

Narrative
Problem Orientated Medical Record
Source Records
Charting by exception
Case management and use of critical pathways

Question 10

A method of documentation that uses a story like format to document information

Answer 10

Narrative Charting

Question 11

A method of documentation that consists of database, problem list, care plan, and progress notes

Progress notes formats ( soap, soapie, pie or dar )

Answer 11

Problem - Oriented Medical Records

Question 12

SOAP and SOAPIE meaning

Answer 12

Subjective
Objective
Assessment
Plan

Intervention
Evaluation

Question 13

PIE meaning

Answer 13

Problem ( soa )
Intervention
Evaluation

Question 14

DAR meaning

Answer 14

Data ( soa )

Action ( pi )

Response ( e )

Question 15

A method of documentation that is organized so each discipline make notations in a separate section

Answer 15

Source Records

Question 16

A method of documentation where in the philosophy behind it is that a patient meets all standards unless otherwise documented

Answer 16

Charting by exception

Question 17

A method of documentation that emphasizes quality, cost effective care delivered within an established length of stay

Answer 17

Case management model

Question 18

A method of documentation that are inter professional care plans that identify patient problems, key interventions, and expected outcomes within an established time frame

Answer 18

Critical pathways

Question 19

Documentation using the Nursing Process

Answer 19

● Assessment data: Initial assessment forms, flow sheets, progress notes (nurses’ notes)

● Nursing diagnoses: Care plans, critical pathways, progress notes, problem lists

● Planning: Nursing care plans, critical pathways, Kardex

● Implementation: Progress notes, flow sheets

● Evaluation: Progress notes

Question 20

Telephone, Verbal and Written Orders

Answer 20

• TO: Health care provider gives orders over the phone.
• VO: Health care provider gives orders to a registered nurse while they are standing near each other.
• Written orders: may be transcribed by nurses or pharmacist. Need to clarify all orders if unsure.