Class 10: Intro to charting Flashcards Preview

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Flashcards in Class 10: Intro to charting Deck (35)
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1
Q

charting by exception

A

is that a patient meets all standards unless otherwise documented. method was introduced in the early 1980’s

2
Q

confidentiality

A

nurses must follow certain principles to maintain confidentiality of patients

3
Q

consultations

A

form of discussion where one professional caregiver gives formal advice about the care of a patient to another care giver

4
Q

Data-Action-Response-Plan (DARP)

A

data (subjective and objective
action or nursing intervention
response of the patient (evaluation of effectiveness)
adresses patient convers: a sign or symptom, condition, nursing diagnoses, behaviour, significant event, or change in patients condition

5
Q

documentation systems

A

a nursing action that produces a written account of pertinent patient data, nursing clinical decisions and interventions and patient responses in a health record

6
Q

health care record

A

or chart, is confidential, permenant legal record of info relevant to patients health care.

7
Q

kardex

A

portable “flip over” file or binder is kept at nursing station

8
Q

personal info protection and electronic documents act (PIPEDA)

A

federal legislation that protects personal info, including health info. describes how private-sector organizations may collect, use or disclose personal in the course of commercial activities

9
Q

referrals

A

an arrangement for services by another care provider

10
Q

reports

A

oral, written or audiotaped exchanged of information between caregivers

11
Q

standardized care plan

A

used to make documentation easier for nurses, only used in some institutions. they are preprinted, established guidelines that are used to care for patients with similar health problems

12
Q

subjective-objective-assessment-plan (SOAP)

A
subjective data (verbalizations of the patient)
objective data (measured and observed)
assessment (diagnosis based on data)
plan (what the caregiver plans to do)
13
Q

WNL

A

within normal limits

14
Q

purpose of reporting

A
  • facilitates communication between health care providers for continuity of care
  • guides professional and organizational performance improvement
  • maintains a legal record of care
  • to limit liability, nursing documentation must clearly indicate that care was given and based on nursing assessment
15
Q

quality documentation and reporting

A
  1. factual
  2. accurate
  3. complete
  4. current
  5. organized
  6. confidential
16
Q

factual reporting and documentation

A

descriptive and objective. avoid charting routine, superficial or irrelevant info.

  • write down using quotation makes and clients exact words or paraphrased without quotations
  • client demonstrating increased agitation, increased pulse and respirations rates NOT client seems anxious.
  • client appeared to be sleeping on all rounds, respirations WNL. NOT client slept well.
17
Q

accurate reporting and documentation

A

use precise measurements. use institution accepted abbreviations, symbols, and systems of measurement

  • avoid misunderstanding by writing in full any abbreviations that may be confusing (OD, od)
  • correct spelling is critical, it demonstrates competency and decreases confusion
  • record is ended with the writers first initial last name, and status including student (O. Skrodolis, CCPNS)
18
Q

complete reporting and documentation

A

complete and thorough

-a great deal of info recorders in narrative when more detail is required

19
Q

current reporting and documentation

A

makes entries promptly and record late entries correctly (e.g. “1100 (late entry for 0845)”

  • client reported seizure activity. medication given with good effect, no further seizure activity reported or observed at this time.
  • some entries must be recorded as they happen VS, pain assessment, medication admin, change in status, admission, discharge, transfer, death
20
Q

organized reporting and documentation

A

write in logical order. be concise, clear and to the point.

21
Q

progress notes (methods of recording)

A

ongoing record of monitoring of a patient progress by members of the health care team

22
Q

narrative notes (methods of recording)

A

traditional method, uses a story life format

23
Q

disadvantages of methods of recording

A

tendency to repeat info, time consuming, requires the reader to sort through much info to locate desired data

24
Q

O/E

A

on examination

25
Q

C/O

A

complained of

26
Q

NYD

A

not yet diagnosed

27
Q

B.R.

A

bed rest

28
Q

BRP

A

bathroom privileges

29
Q

subcut

A

subcutaneous

30
Q

charting by exception

A
  • ONLY chart when something is out of the ordinary occurs and the info cannot be relayed on flow sheets
  • info that is unchanged from the previous day is not documented. e.g. ADL’s, meals, activities
31
Q

confidential reporting and documentation

A

all documentation and recording stays within the health care setting. make references to other clients by initials

32
Q

basic rules for charting

A
  1. factual, accurate, current, complete, organized, confidence.
  2. all sheets have correct name, date and time
  3. use only approved abbreviations and medical terms
  4. write legibly or print
  5. follow all rules of grammar and punctuation
  6. fill all spaces, leave no empty lines
  7. chart after care, not before
  8. chart as soon and as often as possible
  9. chart only what you do
  10. chart facts, avoid judgement terms
  11. chart each departure and return of pt.
  12. sign each block of charting with first initial, last name and designation
  13. chart all ordered care as given or explain deviation
  14. note response to treatment or analgesics
  15. note a late entry as such and then proceed with notation
  16. use names appropriate
33
Q

fixing mistakes in documenting and charting

A

remember that charts are LEGAL DOCUMENTS. all writing must be done in PEN (black). No felt pen, gel pen, erasable pen or pencils
-no erasing, scribbling over or white out on docs. any error must have one line drawn through it with the word “error” written along with your initial

34
Q

what to remember with documenting and charting

A

if it wasn’t documented… it did not happen. clients charts are the first thing to be scrutinized in cases of malpractice or in charges of negligence

35
Q

real charting errors

A

lots of them, spelling is key