Ch. 16 Documenting And Reporting (Week 5 Quiz) Flashcards
What is the goal of nursing documentation ?
To be a clear concise representation of a patients healthcare experience. It should be easily accessible and understandable by ALL members of the healthcare team
What are the 2 things to NEVER do when documenting?
- NEVER document actions of others as though you performed them. (What if they do a bad job? or forget steps? do you want to be responsible?)
- NEVER document before something is due (what if you forget to give the med? Patient then misses a dose because the next nurse thinks they got it.)
What are the ABC’s of documentation?
Hint: important factors in a health record
Accurate Bias-free (no personal feelings) Complete Detailed Easy to read Factual Grammatical Harmless (legally)
What is the purpose of the written record?
- to communicate between providers
- educational tool
- legal documentation of care
- quality improvement (working to make things better)
- research
- reimbursement
_______ ________ documentation is when varying disciplines chart separately (ie physical therapy, social work, dietician, discharge planning). It may lead to data being scattered or fragmented.
Source oriented documentation
Your shift is over and it is time to handoff your patient to the next shift. What are the 3 things you always do?
When documenting, narrate the last thing you did for the patient (and how the patient was when you left them), what needs to be done for the patient by the next nurse’s shift, and how the patient feels.
This type of documentation is organized around patients problems. It allows greater collaboration and REQUIRES all departments to work together and chart in shared notes.
Problem oriented records (POR)
What are the four components of POR’s?
DPPP
- Database: Demographic, H&P, Nsg Assessment and family&social history
- Problem list (pg 294 fig 16-1)
- Plan of care-provider orders+nursing care plan for addressing problems.
- Progress notes - organized according to problem list, each discipline charts in shared notes.
What are common types of charting?
Narrative PIE - Problem Intervention Evaluation SOAPIER Focus CBE - Charting By Exception FACT system Electronic entry
A _________ is when the patients experience is documented in chronological order (like a story). Info may be buried in the text and it’s difficult to track problems because it is long and disorganized. It does tracks patients changing status.
Narrative (narrative format)
SOAP(IER) is the most common type of charting that we use. What does this acronym stand for?
S: subjective data O: objective data A: assessment P: plan I: intervention E: evaluation R: revision
_______ charting views patient’s status from a positive perspective (versus problem oriented). You would use assessment data to evaluate patient care concerns, problems, or strengths. Usually three columns, 1)TIme and Date; 2)Problem being addressed; 3) DAR (data,action,response)
Focus charting
“Focus on the positive.”
What does the acronym FACT mean?
F: flow sheet
A: assessment
C: concise
T: timely entries
Why document the nursing admission assessment?
- To record baseline data and monitor change
2. Help forecast future needs
What are Flow sheets used for?
Hint: RDTIO
- Record routine aspects of care (the flow of care)
- Document assessments (organized according to body systems - the assessment flow)
- Track patient response to care (wound care, pain, IVs)
- Intake&Output records (literally the flow of fluids in and out)
