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CSON > Documentation > Flashcards

Documentation Flashcards

1
Q

Standards Applicable to All Nurses

A

Accurately and completely report and document:
-Client’s status including signs and symptoms
-Nursing care rendered
-Administration of medications and treatments
-Client’s response(s): and
-Contacts with other health care team members concerning significant events regarding client’s status

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2
Q

Document Relevant data

A

accurately and in a manner accessible to the interprofessional team.

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3
Q

Document Problems and Issues

A

in a manner that facilitates the determination of the expected outcomes and plan.

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4
Q

Document Expected outcomes

A

as measurable goals

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5
Q

Document The Plan

A

using standardized language or recognized terminology

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6
Q

Document Implementation and

A

any modifications, including changes or omissions, of the identified plan

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7
Q

Document The Coordination of

A

Care

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8
Q

Document The Results of the

A

evaluation

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9
Q

Document Nursing Practice in

A

a manner that supports quality and performance improvement initiatives.

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10
Q

Patient Records Contain

A

-Patient identification and demographic data
-Informed consent for treatment and procedures
-Admission data
-Nursing diagnoses or problems
-Care plans
-Record of nursing care treatment and evaluation
-Medical History
-Medical Diagnosis
-Therapeutic Orders
-Progress notes
-Physical assessment findings
-Diagnostic study findings
-Patient education
-Summary of operations
-Discharge plan and summary

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11
Q

The Purpose of Records Includes

A

Communication
Legal document
Reimbursement compliance
Education
Research
Auditing and monitoring Supports compliance with standards of care

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12
Q

The chart is a very persuasive witness because

A

it is the description of the facts at the time

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13
Q

Communication is

A
  • Multi-Disciplinary
    -Critical for Continuity and Risk Reduction
    current status/ needs
    progress
    therapies
    consultations
    education
    discharge planning
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14
Q

Documentation must be

A

-Factual

-Accurate

-Complete

-Current

-Organized

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15
Q

Factual documentation is

A

Objective
Descriptive
Subjective (quotes)

NO ASSUMPTIONS OR OPINIONS

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16
Q

Accurate documentation is/has

A

Exact measurements
Clear
Understandable
Standard Abbreviations only
Timed, dated with signature and title
Correct spelling

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17
Q

Complete documentation

A

-Condition change
Onset, duration, location, description, precipitating factors, behaviors
-Do not leave blanks. Use N/A
-Communication with patient and family

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18
Q

Anyone reviewing the chart must be able to understand an accurate, clear and comprehensive picture of

A

-Patient’s needs
-Nurse’s interventions
-Patient outcome

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19
Q

Current documentation

A

-As soon as possible
-Time of occurrence
-Military clock
-Never pre-time,Pre-date, pre-chart. (this is illegal falsification of the record)

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20
Q

1pm

A

1300

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21
Q

2pm

A

1400

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22
Q

3pm

A

1500

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23
Q

4pm

A

1600

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24
Q

5pm

A

1700

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25
Q

6pm

A

1800

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26
Q

7pm

A

1900

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27
Q

8pm

A

2000

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28
Q

9pm

A

2100

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29
Q

10pm

A

2200

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30
Q

11pm

A

2300

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31
Q

12am end of day (midnight)

A

2400

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32
Q

12am begging of day

A

0000

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33
Q

Organized documentation

A

Chronological order
Concise
Clear
To the Point
Complete sentences not needed

34
Q

Terms to Avoid

A

Accidentally
Apparently
Appears
Assume
Confusing
Could be
May be
Miscalculated
Mistake
Somehow
Unintentionally
Normal
Good
Bad

35
Q

Documentation “Don’ts”

A

-Don’t document a patient problem without charting what you did about it.
-Don’t alter a patient’s record – this is a crime.
-Don’t write imprecise descriptions, such as bed soaked, large amount…
-Don’t chart what someone else heard, felt or smelled unless information is critical. Use quotations and attribute remarks appropriately.
-Don’t chart care ahead of time. It’s fraud.

36
Q

Narrative

A

-written in order of patient experience happens.

-Provides details of patient’s care, status, activities, nursing interventions, psychosocial context and response to treatment.
Charting by Exception

37
Q

Problem-Intervention-Evaluation (PIE)

A

Nursing focused instead of medical focused and eliminates need for separate care plan

38
Q

SOAP/SOAPIE/SOAPIER

A

S - Subjective data
O - objective data
A - assessment
P - plan
I - intervention
E - evaluation
R - revision.

39
Q

DAR

A

D - Data
A - Action
R - Response

40
Q

Forms

A

-Nursing admission data forms

-Discharge summary

-Flow sheets and graphic sheets

-Medication Administration Records

-Kardex

41
Q

Flow sheets and graphic sheets

A

-Check list - assessment
-Vital signs
-Intake and Output

42
Q

Medication Administration Records

A

Scheduled meds
unscheduled meds
drug allergies
single order medications

43
Q

Kardex

A

Not a permanent record.
A summary of patient needs and care.
Usually Contains:
- Patient’s data (name, age, marital status, religious preference, physician, family contact).
- Medical diagnoses: listed by priority.
- Allergies.
- Medical orders (diet, IV therapy, etc.).
- Activities permitted.

44
Q

Rules For Paper Charts

A
  • Print or Script
  • BLUE or BLACK Ink
  • NEVER Use White-Out
  • NEVER Use Erasable Ink
  • NEVER Obliterate
  • NEVER erase – NO Pencils
45
Q

Flow Sheets/Forms

A

Vertical or horizontal columns for recording dates and times and related assessment and intervention information:
- Vital Signs
- Intake and Output
- Assessment

46
Q

Nurse’s Progress Notes/Narrative

A

Patient’s condition, problems, and complaints.

Interventions.

Patient’s response to interventions.

Achievement of outcomes.

Additional assessment

***Report given, and report received
Time
Nurse’s name
Important information

47
Q

As a STUDENT in Clinical

A

Confidentiality and compliance with HIPPA are part of your practice
-Do not share information with classmates unless in clinical conference
-Do not access medical records of other patients
-Electronic health records are traceable through login
-CAN cause disciplinary action by employers and dismissal from work or nursing school

48
Q

Students paperwork in clinical practice should not include

A

patient identifiers
Ex. Room number, DOB, demographic information, name

49
Q

Components of Good Documentation

A

Who

What

When

Where

How

Outcome

50
Q

What

A

Assessment findings?
Patient’s complaint
Care you provided

51
Q

When

A

The time when you provided care

52
Q

Where

A

Where did event take place
Where was the treatment given or medication administered

53
Q

How

A

How was treatment completed?
How did the resident tolerate the procedure/treatment

54
Q

Outcome

A

Outcome of the procedure/treatment

55
Q

Follow-up

A

What type of follow-up needed (retaking BP. Pain level…)

56
Q

Accuracy

A

Exact measurements (don’t use about or approximately

57
Q

Specific Aspects of Care

A

-Critical diagnostic results
-Fall reduction
-Infection prevention
-Medications and reconciliation of medications
-Non-conforming patient behavior
-Pain assessment and management
-Patient and family role in safety
-Restraints
-Skin care
-Suicide

58
Q

Notifiying the Provider

A

INCLUDE the full name of the provider.

NOTE the exact time that you notified the provider

STATE the specific laboratory result, symptom, or other assessment data that you reported.

RECORD the provider’s response, using exact words if possible.

INCLUDE any orders which the provider gives. If the provider gives no orders, note this - especially if you anticipated an order. For example, “Dr. Sara Jones informed of oral temperature of 104o F. No orders received.”

In your complete note of the event, include the patient’s other vital signs, relevant observations and any nursing interventions you performed

59
Q

Notifying the Provider Continued

A

Include the commitment for necessary follow-up by provider, such as, “Will visit patient at 0600.”

Include symptoms and parameters such as changes in vital signs, level of consciousness, or pain that the provider defines as indicators for nurses to use in deciding to call the provider again.

It is essential that you note your own actions to assist the patient in addition to documenting your contacts with the provider.

If a provider fails to respond to a page, a telephone message, or fails to order an intervention and thereby creates a risk for the patient, pursue the chain-of-command and notify your direct supervisor.

Record all your actions.

60
Q

Never use labels to

A

describe a patient or patient’s behavior
- ex: Obnoxious, belligerent, rude…

61
Q

Instead of labels

A

Describe patient’s behavior

62
Q

Document Patients rufusal,

A

reason for refusal and what you did about it.

63
Q

Correct

A

all errors promptly, using the correct method.

64
Q

Record

A

all facts; do not enter personal opinions

65
Q

If an order was questioned

A

record that clarification was sought

66
Q

Chart only for

A

yourself, not for others.

67
Q

Keep your computer password

A

secure.

68
Q

Avoid

A

generalizations.

69
Q

Rules for Paper Charting

A

Begin each entry with the date/time and end with your signature and title.
Do not leave blank spaces in nurses’ notes
Write legibly in permanent black/blue ink.

70
Q

Accurate documentation is the best defense for

A

legal claims

71
Q

Must describe exactly what happened to patient and how nurse followed

A

agency standards

72
Q

Try to chart

A

immediately following care provided

73
Q

Care Not Documented is

A

CARE THAT WAS NOT PROVIDED

74
Q

Common Mistakes requiring Legal Action

A

Failing to record health information/drugs

Failing to record nursing actions

Failing to record medications that was given

Failing to record drug reactions/ or change in patient condition

Failing to write legibly or complete

Failing to document discontinued/refusal medication

Failing to notify Dr., nurse, family and recording exact conversation

Failing to record a late entry correctly

Failing to record referrals

Failing to record patient teaching

75
Q

Correct Errors in a paper chart

A

using a single line through entry and your initials (no erasing, “white out”- do not write error or mistake)

Make sure you have the right chart!!

76
Q

Correct Errors in EMR

A

new entry. Explain error.

Make sure you have the right chart!!

77
Q

For a Late Entry in a Paper Chart

A

-Add the entry to the first available line, and label it “late entry” to indicate that its out of sequence, according to facility policy

-Record the date and time of the entry and, in the body of the entry, record the date and time it should have been made

78
Q

For a Late Entry in an EMR

A

change date and time and then document. However…

79
Q

Overall, Documentations SHOULD be

A

-Accurate
-Bias-free
-Complete
-Detailed
-Current
-Organized
-Easy to read and understand
-Factual
-Harmless (legally)

80
Q

Two out of three most frequent allegations against nurses in medical liability claims deal with

A

Documentation: either
absence of documentation (NOT CHARTED = NOT DONE) or
Timing of Documentation (Late entries)

CSON (4 decks)

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