Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

461-Foundations > Documentation Power Point > Flashcards

Documentation Power Point Flashcards

1
Q

Nurses are _____ and ethically obligated to keep all patient information confidential.

A

legally

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Nurses are responsible for ______ records from all unauthorized readers.

A

protecting

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

_____ requires that disclosure or requests regarding health information are limited to the minimum necessary.

A

HIPAA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

______ is anything written or printed as proof of patient actions and activities.

A

documentation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

The care provided as ______ or charting; it should reflect the nursing process.

A

documentation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

______ is a vital aspect of nursing practice.

A

documentation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Information to document

A

Assessments
Medications
Treatments and responses
Client education

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Current documentation standards require that each _____ have an assessment that includes physical, psychosocial, environmental, self-care, patient education, knowledge level, and discharge planning needs

A

patient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Nursing _____ standards are set by federal and state regulations, state statutes, standards of care, and accreditation agencies.

A

documentation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

_____ are when a professional caregiver giving formal advice to another caregiver

A

consultations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

____ are arrangement for services by another care provider.

A

referrals

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Interdisciplinary communication withing the health care team provides _______ among all team members who provided care to the same clients.

A

continuity of care

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Remember, if it wasn’t ______, it wasn’t done!!

A

documented

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Purposes of Records

A 
communication
legal documentation
financial billing/reimbursement
client education
research
auditing/monitoring
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Legal Guidelines for Recording

A

Correct all errors promptly, using the correct method.
Record all facts; do not enter personal opinions.
Do not leave blank spaces in nurses’ notes.
Write legibly in permanent black ink.
If an order was questioned, record that clarification was sought.
Chart only for yourself, not for others.
Avoid generalizations.
Begin each entry with the date/time and end with your signature and title.
Keep your computer password secure.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Guidelines for Quality Documentation and Reporting

A 
Factual
Accurate
Complete
Current 
Organized
Nonjudgmental
Timely
Concise
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Common charting mistakes include failing to document _____ medications

A

discontinued

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Common charting mistakes include writing illegible or _____.

A

incomplete records

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Common charting mistakes include failing to record pertinent health & drug info, nursing actions,
that medications have been given, _____ or changes in client’s condition

A

drug reactions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Methods of recording include a ___ record which is episode oriented, but key info ay be lost form one episode ot another.

A

paper

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Methods of recording include ____ which is a digital version of a patient’s medical record. It integrates all of a patient’s info in one record and improves continuity of care.

A

electronic health record (EHR)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

____ is the traditional method of recording.

A

narrative

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

_____ is a method of recording that is a database that includes a problem list, care plan and progress notes.

A

problem oriented medical record (POMR)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Methods of recording: progress notes include SOAP which stands for:

A

subjective
objective
assessment
plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Methods of recording: progress notes include SOAPIE which stands for:

A 
subjective
objective
assessment
plan
intervention 
evaluation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Methods of recording: progress notes include PIE which stands for:

A

problem
intervention
evaluation

27
Q

Methods of recording: progress notes include Focus Charting or (DAR) which stands for:

A

Data
Action
Response

28
Q

CBE in documentation stands for ___.

A

charting by exception

29
Q

____ are a separate section for each discipline to document.

A

source records

30
Q

CBE focuses on documenting ____.

A

deviations

31
Q

Case management plan and critical pathways incorporate a muldisciplinary approach to _____ and variances.

A

care

32
Q

_____ is a multidisciplinary approach to document client care

A

critical pathways

33
Q

Standardized plan of care is summarized into ____ with a case management plan.

A

pathways

34
Q

Critical pathways include a ____page integrated care plan for problems and includes key interventions and expected outcomes.

A

1-2

35
Q

_______ Guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems

A

admission nursing history form

36
Q

______ Help team members quickly see patient trends over time and decrease time spent on writing narrative notes

A

flow sheets and graphic records

37
Q

_____ is a A portable “flip-over” file or notebook with patient information

A

patient care summary or Kardex

38
Q

_____ are a Preprinted, established guidelines used to care for patients who have similar health problems

A

standardized care plans

39
Q

Common record keeping forms also include the ____ summary forms and acuity records.

A

discharge

40
Q

Forms that may be used by nurses

A

Progress notes

Flow sheets

D/C summaries

Client education

Kardexes

MARs (Medication Administration Records)

41
Q

What to document?

A 
Your interventions w/ patient’s response and your evaluation
Any significant changes or events in condition
Informed consent
Patient teaching
Any attempts to contact medical staff
Patient leaving AMA
Patient’s refusal of treatment
Spiritual concerns
Use of restraints
Medication Administration
42
Q

Medicare has specific guidelines for establishing eligibility for _____.

A

home care

43
Q

_____ guidelines for establishing a patient’s home care cost reimbursement serve as the basis for documentation by home care nurses.

A

Medicare

44
Q

______ is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance.

A

Documentation

45
Q

Nurses need to document all their services for .

A

payment

46
Q

Governmental agencies are instrumental in determining standards and policies for ______.

A

documentation

47
Q

The ______ of 1987 includes Medicare and Medicaid legislation for long-term care documentation.

A

Omnibus Budget Reconciliation Act

48
Q

The department of health in states governs the _____ of written nursing records.

A

frequency

49
Q

Reporting Care

A 
Change-of-shift
Hands off care
Telephone report to MD
Transfer/Discharge reports
Oral
Written
Computer-based
50
Q

A ____ report occurs with transfer of patient care and provides continuity and individualized care.
Reports are quick and efficient.

A

hand-off

51
Q

_______ include Situation-background-assessment-recommendation (SBAR) and make sure to document every call and Read back the orders.

A

telephone reports and orders

52
Q

_______ are Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient.
Follow agency policy.

A

incident or occurrence reports

53
Q

_____ is a Report written about any event not consistent with routine operation of the HC unit or routine care of the client

A

incident/occurrence report

54
Q

An incident/occurrence report should be ______, accurate report exactly what is observed + F/U care given

A

Concise

55
Q

An incident/occurrence report is part of quality ______with the institution

A

improvement

56
Q

An incident/occurrence report investigates the occurrence/circumstances and
may result in ____ that are needed to prevent recurrences

A

changes

57
Q

Critical Elements of an incident report

A 
Date/time of occurrence
How nurse found the client
Witness info
Assessment of client’s injury
Actions taken + FU notations
Who finds/witnesses the incident writes the report
Not part of the medical record
58
Q

_____ is A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice

A

nursing informatics

59
Q

_____ is a group of systems used in a health care organization to support and enhance health care

A

Health Care Information System (HIS)

60
Q

_____ Consists of one or more
Computerized clinical information systems (CISs) and/or
Administrative information systems

A

nursing informatics

61
Q

Advantages of NISs

A 
IIncreased time to spend with patients
Better access to information
Enhanced quality of documentation
Reduced errors of omission
Reduced hospital costs
Increased nurse job satisfaction
Compliance with accrediting agencies
Common clinical database development
62
Q

Protection of the confidentiality of patients’ health information and the security of computer systems are ____ that include log-in processes, audit trails, firewalls, data recovery processes, and policies about handling and disposing of data to protect patient information.

A

top priorities

63
Q

You, and only you, should chart the care you give and _____ State’s Nursing Practices Acts prohibit having another chart for you on medical records.

A

supervise.

64
Q

____ of all malpractice suits are decided based on documentation (or lack thereof).

A

One fourth

461-Foundations (45 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions