Ch. 18: Documenting and Reporting-MJ

Question 1

The act of recording patient status and care in written or electronic form or in combination of the two forms

Answer 1

Documenting

Question 2

What other terms are considered documenting?

Answer 2

Documenting, reporting, charting

Question 3

What should be included in the documentation?

Answer 3

Health history
Exams
Tests
Treatment
Outcomes

Question 4

What is the purpose of documentation?

Answer 4

To provide continuity of care among all team members who provide care to the same patient

Question 5

Documentation should always reflect the _____

Answer 5

Nursing process

Question 6

Documentation provides communication between ____-

Answer 6

Providers

Question 7

Documentation does ____ of care

Answer 7

Continuity

Question 8

Documentation is an ____ tool and can be used during ____

Answer 8

Education tool; research

Question 9

Documentation give a _____ of care

Answer 9

Legal document

Question 10

T/F: Documentation provides quality improvement and reimbursement.

Answer 10

True

Question 11

What are the 4 advantages of written documentation?

Answer 11

• Familiar
• Does not require a large database networks and is secure to function
• Not dependent on power/electricity
• Inexpensive

Question 12

What are the disadvantages to written documentation?

Answer 12

• Access may be delayed
• Retrieving info may be slow
• Time consuming
• High risk patient error
• Storage is expensive
• Difficult to protect confidentiality

Question 13

What are the advantages to electronic documentation?

Answer 13

• Communication is improved among health providers
• Improved access to info
• Saves time
• Improves the quality of care

Question 14

What are the disadvantages to electronic documentation?

Answer 14

• Expensive
• Electrical issues
• Difficulties with learning
• Lack of integration

Question 15

What are some examples of common types of charting?

Answer 15

Narrative, PIE, SOAPIER, Focus, Charting by Exception, FACT system, and electronic entry format

Question 16

Which charting type tells the story of the patient?

Answer 16

Narrative

Question 17

What is the advantage to narrative charting?

Answer 17

Helps set a goal for the patient and tracks the clients health status

Question 18

What are the disadvantages to narrative charting?

Answer 18

Time consuming, disorganized, contain multiple entries, must read the entire note of the client, and does not readily identify problems and trends

Question 19

What does PIE stand for?

Answer 19

Problem intervention evaluation

Question 20

What are the advantages to PIE charting?

Answer 20

Eliminates the need for a separate care plan and provides a nursing focus rather than a medical focus record

Question 21

What is the disadvantage to PIE?

Answer 21

Does not document the planning portion of the nursing process

Question 22

What does SOAP(IER) stand for?

Answer 22

Subjective data
Objective data
Assessment
Plan
Intervention
Evaluation
Revision

Question 23

Advantages of SOAPIER: To shift the focus from the patient to the ___, promoting a medical model instead of the _____

Answer 23

Disease, nursing process

Question 24

Disadvantage of SOAPIER: ___ & _____ (may be a repeat of responses for the client); nurses may write a narrative instead of the single problem

Answer 24

Inefficient and ineffective

Question 25

What charting is this: Review the clients status from a positive rather than a problem oriented prospective

Answer 25

Focus charting

Question 26

The advantages of focus charting is that it focuses on the signs/symptoms (objective data), it works well in ___ settings and areas where the same care and procedures are repeated frequently.

Answer 26

Acute

Question 27

The disadvantages of focused charting is it may lead to _____ labeling focus of notes and difficulty in ____ patient progress

Answer 27

Inconsistent; tracking

Question 28

What does CBE stand for?

Answer 28

Charting by exception

Question 29

Charting by exception charts only ____ findings or ____ to standards of care

Answer 29

Significant, exceptions

Question 30

Advantage or disadvantage of CBE: It reduces the amount of time spent on documentation repetitive charting on routine care, and provides an easier and understood record

Answer 30

Advantage

Question 31

T/F: The CBE disadvantage is that it omits data that may be significant, and nurses may forget how to chart.

Answer 31

True

Question 32

What does FACT documentation stand for?

Answer 32

- Flow sheet - Assessment - Concise, integrate progress notes and flow sheets - Timely entries

Question 33

FACT documentation eliminates the need to chart _____

Answer 33

Normal findings

Question 34

In FACT documentation, can nurses forget the skill of charting?

Answer 34

Yes