Documentation

Question 1

maintaining pt confidentiality on computers (6)

Answer 1

• Do not share personal password
• Never leave the computer unattended after logging in
• Do not leave pt info on screen where others can see
• Shred all unnecessary sheets - cut pt’s ID info off paper if you must take it out of facility
• IT must install firewall
• Follow policy for charting sensitive info

Question 2

purposes of pt records (8)

Answer 2

• Communication - prevents repetition & delay in care
• Planning care - evaluate plan’s effectiveness
• Auditing health agencies - can be reviewed for quality assurance
• Research - info about populations of pts can help with treatment plans for others
• Education
• Reimbursement - must contain correct DRG (diagnosis related groups)
• Legal documenation - admission in court as evidence unless pt objects
• Health care analysis - ID agency needs - overutilized & underutilized resources

Question 3

most common type of charting

Answer 3

source oriented records

Question 4

easily located each discipline’s form

easy to trace info specific to one’s discipline

info about particular problems distributed throughout

Answer 4

source oriented charting

Question 5

must chart in clear, chronologic, coherent manner

Answer 5

narrative charting

Question 6

Data arranged according to pt’s problem

encourages collaboration

alerts caregivers to pt needs

caregivers differ in ability to use

takes constant vigilance to maintain updated list

inefficient because assessments/interventions must be repeated

Answer 6

problem oriented medical record

Question 7

parts of the problem-oriented chart (4)

Answer 7

database

problem list

plan of care

progress notes

Question 8

SOAPIER documentation

Answer 8

• S - subjective
• O - objective
• A - assessment
• P - plans
• I - interventions
• E - evaluations
• R - revisions

Question 9

focuses on pt’s strengths

Answer 9

focus charting

Question 10

DAR

Answer 10

data, action, response

Question 11

CBE

Answer 11

charting by exception

Question 12

only charting what is different/problematic/unexpected

eliminates lengthy, repetitive notes

makes pt changes more obvious

risk for negligence

Answer 12

charting by exception

Question 13

advantages of computer documentation (5)

Answer 13

• Focus on pt outcomes
• Links sources to pt info
• Bedside terminals eliminate paper notes
• Legibility improved
• Improves communication

Question 14

disadvantages of computer documentation (4)

Answer 14

• Privacy may be infringed
• Tech breakdowns
• Expensive
• Extended training required

Question 15

Assign a case manager to pt

ensures quality, cost-effective care delivered w/i length of stay

Answer 15

case management model

Question 16

critical pathways used for…

Answer 16

common diseases

Question 17

variance

document…

Answer 17

a goal that was not met

• Document actions taken to correct
• Document justification of actions taken

Question 18

Concise method of organizing & recording data

Cards kept in portable index file or computer

Info quickly accessible

Pertinent info about pt arranged in sections

Answer 18

kardexes

Question 19

sections in a kardex (6)

Answer 19

• Allergies
• List of meds
• Daily treatment & procedures
• Diagnostic procedures
• Physical needs to be met
• Stated goals

Question 20

examples of flow sheets

Answer 20

• Graphic record - VS, weight, etc
• I & O record
• MAR - medication administration record
• Skin assessment record

Question 21

Completed when pt discharged or transferred

Answer 21

discharge/referral summary

Question 22

components of a d/c and referral summary (8)

Answer 22

• Description of pt physical, emotional, mental status
• Resolved health problems
• Tx to be continued
• Current meds
• Restrictions
• Self-care abilities
• Support networks
• Referral services

Question 23

administers medicare

Answer 23

Health Care Financing Administration

Question 24

regulates documentation for long term care

Answer 24

Omnibus Budget Reconciliation Act (OBRA)

Question 25

**long term care documentation** * Minimum Data Set assessment & screening w/i ______ of admission * Plan of care w/i _____ of admission * Review & revise plan of care every \_\_\_\_\_\_ * Report any change in pt condition to Dr & family w/i _____ & measures taken to change condition

Answer 25

4 days 7 days 3 months 24 hours

Question 26

there must be an RN in a long term care facility at least ___ hrs per day

Answer 26

8

Question 27

\_\_\_\_\_\_\_ requires standardized documentation for home health care

Answer 27

Health Care Financing Administration

Question 28

2 record required for home health care

Answer 28

* Home health certifications & plan of treatment form * Medical update & pt info form

Question 29

how to sign documentation

Answer 29

“S. Boyer, SN”

Question 30

documentation NOs (6)

Answer 30

* chart in advance * Leave blank space - strike through empty space & sign * Use vague terms * Alter record * Record assumptions * Include “pt” or pt's name or include “I did…” (conciseness)

Question 31

* Ask & respond to questions * Provide basic IDing info * ISBAR

Answer 31

change of shift report

Question 32

used to report to other caregivers about a pt's situation

Answer 32

ISBAR

Question 33

rules about telephone/verbal orders (5)

Answer 33

* **Write** complete order down * “T-O” - telephone order; “V-O” - verbal order * “Dr. XYZ/S. Boyer” * **Read** it back to ensure accuracy * **Question** any order unusual or contraindicated * Have PCP verbally **validate** read-back * **Countersign** by PCP in 24hr

Question 34

* Meeting to discuss potential solutions to pt problems * Allows each nurse opportunity to offer opinion * Other providers invited to offer expertise

Answer 34

plan of care conference

Question 35

* 2+ nurses visit pts at bedside, often with case manager * Obtain info that will help plan nursing care * Provide pt opportunity to discuss care * Use simple terms for pt’s understanding

Answer 35

nursing rounds

Question 36

Joint Commision requires care plans to include… (5)

Answer 36

1. Evidence of client **assessment** 2. Nursing **diagnosis** 3. Nursing **interventions** 4. Client **outcome** 5. Current nursing care **plan**

Question 37

RAI and MDS use

Answer 37

screening tool to establish a baseline of new incoming clients into a long-term care facility and additional periodic documentation reviewing and revising the assessment as clients’ needs change

Question 38

elements of malpractice

Answer 38

**(1) a professional duty owed to the patient; (2) breach of such duty**; (3) injury caused by the breach; and (4) resulting damages