Common Record-Keeping Forms - Documenting and Reporting

Question 1

The ___ form guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems.

Answer 1

history

Question 2

Data on ___ forms provide baselines that can be compared with changes in the patient’s condition.

Answer 2

history

Question 3

A nursing ___ form is completed when a patient is admitted to a nursing care unit.

Answer 3

history

Question 4

Acute and critical care nurses commonly use ___ sheets and graphic records to document physiological data and routine care.

Answer 4

flow

Question 5

Within a computerized documentation system, these forms allow the nurse to quickly and easily enter assessment data about a patient, such as vital signs, admission and/or daily weights, and percentage of meals eaten.

Answer 5

flow sheets

Question 6

Facilitate the documentation of the provision of routine, repetitive care, such as hygiene measures, ambulation, and safety and restraint checks. These documents provide current patient information accessible to all members of the health care team and help team members quickly see patient trends over time.

Answer 6

Flow sheets

Question 7

Any occurrence on a flow sheet that is unusual or represents a significant change in a patient’s condition is explained in detail in a ___ note. For example, if a patient’s blood pressure becomes dangerously high, you first complete and record a focused assessment and then document the action taken in a ___ note.

Answer 7

progress x2

Question 8

Benefits of Using a Flow Sheet

• Information is accessible to ___ members of the healthcare team
• Time spent on writing a narrative note is d___
• Information is c___
• Errors resulting from transfer of information are d___
• Team members can q___ see trends over time.

Answer 8

all

decreased

current

decreased

quickly

Question 9

Some agencies have computerized systems that provide basic, summative information in the form of a patient care s___. This is printed out for each patient during each shift. This s___ is continually updated and provides the nurse with a current detailed list of orders, treatment, and diagnostic testing.

Answer 9

s-ummary

Question 10

In some settings, a K___ system, a portable “flip-over” file or binder, is kept at the nurses’ station. Most K___ forms have an activity and treatment section and a nursing care plan section that organize information for quick reference as nurses give change-of-shift reports or make walking rounds.

Answer 10

K-ardex

Question 11

An updated K___form eliminates the need for repeated referral to the chart or computer record for routine information throughout the day.

Answer 11

K-ardex

Question 12

Information commonly found on the patient care ___ or ___ form includes the following:

• Basic demographic data (e.g., age, sex, religious affiliation)
• Hospital identification number
• Physician’s name
• Primary medical diagnosis
• Medical and surgical history
• Current prescriber’s treatment orders to be carried out by the nurse (e.g., dressing changes, ambulation, glucose monitoring)
• Nursing care plan
• Nursing orders (e.g., education sessions, symptom relief measures, counselling)
• Scheduled tests and procedures
• Safety precautions to be used in the patient’s care
• Factors related to activities of daily living
• Contact information about nearest relative or guardian or person to contact in an emergency
• Emergency code status
• Allergies

Answer 12

summary / Kardex

Question 13

Some institutions use s___ care plans to make documentation easier for nurses. The plans, based on the institution’s standards of nursing practice, are preprinted, established guidelines that are used to care for patients who have similar health problems.

Answer 13

s-tandardized

Question 14

After a nursing assessment is completed, the staff nurse identifies the standard care plans that are appropriate for the patient. The care plans are placed in the patient’s health care record. The st___ plans can be modified (and changes are noted in ink) to individualize the therapies.

Answer 14

st-andardized

Question 15

Most st___ care plans also allow the nurse to write in specific goals or desired outcomes of care and the dates by which these outcomes should be achieved.

Answer 15

st-andardized

Question 16

One advantage of st___ care plans is establishment of clinically sound standards of care for similar groups of patients.

Answer 16

st-andardized

Question 17

These standards can be useful when quality improvement audits are conducted. These care plans can help nurses recognize the accepted requirements of care for patients and also improve continuity of care.

Answer 17

Standardized care plans

Question 18

The major disadvantage is the risk that the st___ plans prevent nurses from providing unique, individualized therapies for patients.

Answer 18

st-andardized

Question 19

Cannot replace the nurse’s professional judgement and decision-making. In addition, care plans need to be updated regularly to ensure that content is current and appropriate.

Answer 19

Standardized care plans

Question 20

Multi___ involvement in discharge planning helps ensure that a patient leaves the hospital in a timely manner with the necessary resources in place.

Answer 20

Multi-disciplinary

Question 21

• Use clear, concise descriptions in the patient’s own language
• Provide step-by-step instructions for how to perform any procedure that the patient or family will be doing independently (e.g., emptying a urinary catheter or self-administration of an injectable medication). Reinforce explanation with printed instructions.
• Identify precautions to follow when performing self-care or administering medications
• Review signs and symptoms of complications that a patient or family member needs to report to a health care practitioner
• List names and phone numbers of healthcare providers and community resources that the patient or family member can contact
• Identify any unresolved problem, including plans for follow-up and continuous treatment
• List actual time of discharge, mode of transportation, and who accompanied the patient

Answer 21

Discharge summary information

Question 22

Ideally, discharge planning begins at ___.

Answer 22

admission

Question 23

The nurse needs to revise the care plan as the patient’s condition c___.

Answer 23

c-hanges

Question 24

The patient and family members need to be involved in the ___ planning process so that they have the information needed to return the patient home.

Answer 24

discharge

Question 25

• Instruction about potential food-drug interactions, nutrition intervention, and modified diets
• Rehabilitation techniques to support adaptation to, or functional independence in, the environment, or both
• Access to available community resources
• Circumstances in which patients should obtain further treatment or follow-up care
• Methods of obtaining follow-up care
• The patient’s and family’s responsibilities in the patient’s care
• Medication instructions, including the times and reasons to take each medication, the dose, the route, precautions, possible adverse reactions, and information about when and how to get prescriptions refilled

Answer 25

Discharge information

Question 26

A common standard in nursing practice is to e___ patients about the nature of their disease process, its likely progress, and the signs and symptoms of complications.

Answer 26

educate

Question 27

Discharge teaching that was provided upon discharge remains on the E___ ___ ___.

Question 28

D___ summary forms help make the summary concise and instructive.

Answer 28

Discharge

Question 29

A s___ form emphasizes previous learning by the patient and family and care that should be continued in any restorative care setting. When given directly to patients, the form may be attached to pamphlets or teaching brochures.

Answer 29

s-ummary