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Foundations Test 4 > Charting > Flashcards

Flashcards in Charting Deck (38):
1

Potter and Perry documentation definition

Anything written or printed that is relied on as a record of proof for authorized persons.

2

Nursing Practice Guidelines: Documentation

"Any written or computer generated information about a client that describes care or service provided to that client."

3

the medical record:

should be organized, clearly written, synopsis of patient's course (admission to discharge), factual, complete and timely documentation

4

nurses are legally and ethically obligated to keep client information

confidential

5

nurses are responsible for protecting records from all

unauthorized readers

6

HIPPAA act requires

disclosure or requests regarding health information

7

the joint commission requires each client have an assessment:

physical, psychosocial, environment, self-care, client education, and discharge planning needs

8

record or chart:

confidential permanent legal document

9

reports:

oral, written, audiotaped exchange of information

10

consultations:

a professional caregiver providing formal advice to another caregiver

11

referrals:

arrangement for services by another care provider, ex. home health

12

purposes of records

communication, legal documentation, financial billing, education, research, auditing/monitoring

13

communication

have to have providers

14

legal documentation

pursue or defend medical practices; if the nurse didn't chart it then the nurse didn't do it

15

education

learn from charts so helps practice

16

research

group data to see if variables increase/decrease

17

auditing/monitoring

patient care manages and people ho do qualify assessment on chart

18

guidelines for quality documentation and reporting

factual, accurate, complete, current, organized

19

factual document (not example)

don't state a patient is drunk

20

example of accurate documentation

wound 10 cm deep, 10 cm wide, 10 cm long

21

organized documentation

logical guideline

22

how to document error in chart

(mark out mistake with line threw it) write error over mistake and write initials

23

legal guidelines for documentation (1-11)

1. erasing/changing 2. critical/retaliatory remarks (always factual observations) 3. error correction 4. factual 5. blank spaces 6. legibility 7. clarification of orders 8. only chart for self 9. avoid generalized statements 10. time and sign correctly 11. keep password to myself

24

how I would sign my name for charting

Rachael Garland TWC-FSN

25

record only what you

see, hear, feel, smell, measure

26

don't chart

inferences or assumptions

27

keep records

intact

28

don't chart symptom without also

charting what was done

29

don't alter

a client's record... criminal offense

30

when charting don't

erase, apply white out, or scratch out errors

31

do not document what type of remarks

critical or retaliatory remarks about patient or care by other health care professionals, do not enter personal opinions; (char only objective and factual observations of patient's behavior, quote all patient comments)

32

all documentation must be

factual

33

while documenting do not leave

black spaces; other state can come and but in information that is false ( can go back and put in late entry)

34

record all written entries

legibly and in black ink

35

if an order is questioned, record

that clarification was sought

36

only chart for

self

37

when charting avoid

generalized statement; these are subjective

38

how you would begin and end each entry

begin each entry with date and time and end with your signature and title