Lecture 4 - documentation

Question 1

chart

Answer 1

A document that may consist of a single form or a number of forms compiled to provide a complete record of patient care

Question 2

documentation

Answer 2

any written or electronically generated information about a client that describes the care or service provided to that patient

Question 3

what are the 4 min reasons for documentation?

Answer 3

1. vital for safe, ethical, and effective nursing practice
2. reflects knowledge, skills and judgments
3. reflects patient’s perspectives
4. promotes accountability, quality care, communication, nursing’s contribution to health care

Question 4

why is documentation necessary? (5)

Answer 4

1. Legal and professional
2. Helps coordinate care
3. Prevents repetition
4. Promotes accuracy in care
5. Allows for efficient use of time

Question 5

what are the consequences of poor documentation?

Answer 5

1. may not be continuity and consistent care
2. Omission or duplication of treatments
3. Inappropriate care decisions
4. Inability to evaluate effectiveness of care /treatments
5. Inability to respond appropriately to changes in patient’s health status

Question 6

how is communication a tool?

Answer 6

helps us make good care decisions between all health care providers

Question 7

how does documentation promote quality improvement and risk management?

Answer 7

• Evaluate effectiveness of our nursing care plan interventions
• Promotes patient safety

Question 8

how does documentation promote professional accountability

Answer 8

-Reflects our professional judgment, assessment, coordination of care, decisions, actions and evaluation

Question 9

how does documentation provide liability protection?

Answer 9

• Our charting can be used as evidence in a court of law

- Our charting needs to be specific, clear, and outlines the patient’s response to treatment/interventions

Question 10

how does documentation expand the science of nursing?

Answer 10

• Source of data for nursing and health research
• Identifies the impact of nursing interventions, evaluates patient outcomes and identifies gaps or concerns in the provision of care

Question 11

how can documentation improve funding and resource management?

Answer 11

Administrators can use documentation to support requests for additional funding and to help manage current resources

Question 12

how does documentation promote education?

Answer 12

Opportunity to teach and learn

Question 13

what are the regulatory bodies for documentation?

Answer 13

• PIPEDA
• HIPA
• CNA Code of Ethics
• CNPS
• SRNA

Question 14

who should document the care?

Answer 14

if there are 2 people giving care, the person with first hand knowledge should document it.
-you saw it or you did it, YOU DOCUMENT IT

Question 15

third party documentation. when is it acceptable, when it is not?

Answer 15

acceptable when:

• Designated recorder (ex- OR)
• Auxiliary or external personnel (unregulated care providers may not be able to document)
• Client or family
• Students (can document but may require co-sign)
• Co-signing and countersigning entries (ex- narc waste)

Question 16

how should we doccument?

Answer 16

• need date, time, signature, designation
• clear, concise, unbiased, accurate
• do not label, argue, complain, or criticize
• objective (if using subjective need quotations)
• precise descriptions
• • avoid using vague phrases and the words “appears, seems, and apparently” as well as slang
• • don’t need to use complete sentences (a, also, is, are, were, the can probably be omitted)

Question 17

who should we not use “appears, seems, or apparently?”

Answer 17

suggests that the nurse doesnt know the facts

Question 18

what information is provided with the mater signature sheet?

Answer 18

• record of caregivers
• printed name, signature, initials, designation, date
• available on each individual chart

Question 19

what information do we document?

Answer 19

all aspects of the nursing process (assessment to evaluation)

• has the intervention worked?
• anything clinically significant (the abnormal)
• all information that will allow for seamless delivery of safe competent care between shifts.

Question 20

besides care, what else is documented?

Answer 20

admissions, transfers, transport, and discharge information

Question 21

what is included in discharge documentation?

Answer 21

• Patient status at discharge
• Instructions provided to the patient (both written and verbal)
• Preparing patient for any transitions (what to expect in the course of recovery)
• Arrangements for follow-up (appointments made or need to be made)
• Ensuring that the patient understands teaching and, if appropriate, family’s involvement

Question 22

beyond the basics, what does documentation allow for?

Answer 22

communication between all health care providers
-client education (what was taught, how they comprehended the information, information handouts, outstanding learning needs)

Question 23

why is it important to document risk taking behaviours?

Answer 23

• regardless of teaching , patients have their right to make their own decisions

Question 24

what should nurses do if pt’s go against medical advice?

Answer 24

• when patients choose to go against medical advice and have been informed of associated risks you MUST document what was taught, the associated risks for their behaviour and our recommendations
• fill out incident report

Question 25

narrative charting

Answer 25

gives key elements

• Traditional paragraphs, each group has it’s own place, unstructured, refers to patient only
  ex) on nursing notes

Question 26

what are the advantages and disadvantages of narrative charting

Answer 26

Advantages
-familiar, easily combined, easy to use, key observations, useful in emergency

Disadvantages
-lack of structure, variable quantity/quality, does not reflect nursing process, content not defined

Question 27

charting by exception

Answer 27

only key elements to the normal are recorded
-includes: 
Flow sheets
Clinical standards
Standardized care plans
Progress notes

Question 28

charting by exception:

flow sheets

Answer 28

provides key elements in a More structured way, flow of information, and is used with other forms

Question 29

charting by exception:

flow sheets - advantages and disadvantages

Answer 29

Advantages
Saves time, prevents duplication, easier to retrieve, allows comparison

Disadvantages
Limited use

Question 30

confidentiality

Answer 30

“ensure that information is accessible only to those who are authorized to have access”

-patient is entrusting nurse with secrets

Question 31

what are the general guidelines for documentation? - what to do

Answer 31

• date and year on note page (MM/DD/YYYY)
• patients name (addressograph)
• write legibly
• proper grammar and spelling
• black or blue INK
• approved abbreviations
• chart chronologically and promptly
• chart AFTER care is given
• correct mistakes
• do not tamper
• only chart your care
• sign entries
• dont leave blank spaces (fill space with line)
• fill in all spaces on forms that do not apply with N/A

Question 32

what are late enteries

Answer 32

applicable when you want to chart for care done at (ex 0830 when someone already put 0900)

Question 33

how do you insert late entries?

Answer 33

• Add the entry on the first available line
• Label the entry “Late Entry” to indicate that it is out of sequence
• Record the time and date of entry
• In the body of the entry, record the time and date it should have been made

Question 34

what do you do when you make a mistake?

Answer 34

• put a single line through the mistake with “void” and initials above it
• *do not use white out and do not use pencil

Question 35

what is essential information when charting?

Answer 35

• Assessment of patient’s health status
• Changes in functioning
• Symptoms/signs that are severe, recur, worse indicate a complication
  
  • Not relieved–> danger signal
• Nursing actions and patient’s response
• Advocacy undertaken (and education)
• Visits by others and information reported

Question 36

what are the 6 basic guidelines for documentation?

Answer 36

1. Factual
2. Accurate
3. Complete
4. Current
5. Organized
6. Confidential

Question 37

SOAPIER for documentations

Answer 37

S= Subjective
O= Objective
A= Assessment
P= Plan
I= Intervention
E= Evaluation
R= Revisions (any changes in your plan of care)

Question 38

what are important components for verbal reports?

Answer 38

**Quick summary of pt’s needs, behaviour, and important information

• Follows a logical sequence
• Clear, concise, accurate
• Highlight important information
• Avoid bias
• Includes important tests and treatments
• Ensure confidentiality
• Oral report, Taped report

Question 39

ISBARR for verbal report

Answer 39

I=Identify
S=Situation
B=Background
A=Assessment
R=Recommendation 
R=Read back