Documentation

Question 1

what is the purpose of documentation?

Answer 1

communication
health care analysis
auditing
research 
reimbursement
education
legal documentation
planning client care

Question 2

how does documentation serve as a form of communication?

Answer 2

health care workers are able to communicate with other health care workers

Question 3

how does documentation allow for planning client care?

Answer 3

use of baseline data to prescribe and care

Question 4

how does documentation help health care analysis?

Answer 4

help determine needs and under and over utilized services

Question 5

how does documentation help research?

Answer 5

data can help build treatments

Question 6

how does documentation help education?

Answer 6

students like me!

Question 7

how does documentation help audit health agencies?

Answer 7

is the health agency meeting its standards?

Question 8

how does documentation help reimbursement?

Answer 8

insurance, medicare, medicaid

Question 9

how does documentation help with legal documentation?

Answer 9

it can serve as evidence in court

Question 10

“the nurse has a duty to maintain confidentiality of all patient information”

Answer 10

ANA code of ethics

Question 11

what are a few critical issues in documentation

Answer 11

opinons vs. facts
careful faxing
incorrect spelling
don't write error!
dont erase

Question 12

what are the federal regulations for documentation

Answer 12

medicare and medicaid

Question 13

what are the state and federal regulations of documentation

Answer 13

JCAHO

Question 14

what are the different types of reports

Answer 14

change of shift
telephone reports
telephone roders
care plan conferences
nursing rounds

Question 15

what does a nursing round consist of?

Answer 15

2+ nurses to obtain info, evaluate care and include patient on care

Question 16

what does SBAR stand for?

Answer 16

situation
background
assessment
recommendation

Question 17

what are the verbal handoff communication tools?

Answer 17

I PASS the BATON
I SBAR
PACE
5 P’S

Question 18

what does I PASS the BATON stand for?

Answer 18

intro, patient, assessment, situation, safety, concern, background, actions, timing, ownership and next

Question 19

what does PACE stand for?

Answer 19

patient/problem, asssessment/actions, continuing treatment/changes, and evaluation

Question 20

what are the 5 P’S

Answer 20

patient
plan
purpose
problems
precautions
physician

Question 21

what is a POLST?

Answer 21

provider’s order for life sustaining treatment

Question 22

objective and nonjudgemental
accurate timely and pertinent
summary of activities, observations, and actions performed are all included in what?

Answer 22

reporting

Question 23

closed loop communication ensures information conveyed from sender is understood by receiver as intended

Answer 23

check back

Question 24

how do we communicate when we are concerned?

Answer 24

cus

Question 25

what does cus stand for

Answer 25

i am CONCERNED
i am UNCOMFORTABLE
this is a SAFETY ISSUE

Question 26

when is an incident report used?

Answer 26

when any event not consistent with routine care of a client

Question 27

what is a flow sheet?

Answer 27

quick nursing data including….

graphic record
intake and output record
med administration record
skin assessment record

Question 28

what is a kardex?

Answer 28

organization and recording method for data on client

Question 29

documentation system in which only abnormals are charted

Answer 29

charting by exception

Question 30

clients concern and strengths the focus, usually in three columns

Answer 30

focus charting

Question 31

goal not met in critical thinking

Answer 31

variance