Documentation Flashcards
What are the four reasons why we document in the medical record?
- Proof care was rendered
- Provides data continuity
- Communication tool
- Permanent legal record
List six occurrences when to document
- Baseline assessment
- Change from baseline assessment
- Change in patients conditions
- Procedure or treatment
- Medication given and patient response
- Patient teaching
What does SMART communication stand for?
S: Simple: Keep message clear and simple
M: Meaningful: think about what and why you are sending the message
A: Actual: just report the facts
R: Read: Make sure you are sending the message you intend
T: Teach: other about SMART communication
What is the role of the licensed nurse prior to Tx initiation?
Assess abnormal findings from data collections, determine appropriate interventions (based on physician orders) and contact physician if needed.
What is the role of the PCT prior to Tx initiation?
Complete data collection and PCT must notify the RN if there are any abnormal findings prior to the initiation of tx.
Once the treatment is complete and the patient has been rinsed back, what data should you document?
- blood pressure/heart rate
-temperature - respiratory rate
- weight
What are possible consequences of poor or incomplete documentation?
Entries may be discarded if unable to be read
can be left open to interpretation
attack on your care
How do you document late entries?
From policy 03-02-02: Medical Record Preparation and Charting guidance
-Late entries: if unable to chart immediately after rendering a service or at the time of an observations, the teammate is to make the appropriate entry ASAP.
-Electronic: If documenting within the electronic medical record, the notations will automatically contain your electronic signature, date, and time
-Paper Chart: the late entry must be signed by the person making the late entry. The late entry must be timed and dated at the time it is entered.
How do you document charting errors?
When documenting on paper draw a singled line through the entry, date/signature/teammate credentials, chart the correct information. If documentation in an electronic health record system follow facility procedure for that system.
What is the preferred location for taking an accurate blood pressure?
Upper, non access arm.
What BP reading error can be caused by an incorrect cuff size?
Cuff too small: reading may be higher than actual BP
Cuff too Large: reading may be lower than actual BP
What is a normal pre-treatment blood pressure?
Systolic equal to or less than 180mm/Hg or equal to or greater than 90mm/Hg and Diastolic less than 100 mm/hg
What is the normal heart rate range?
60-100 beats/minute
What is the normal respiratory range?
12-16 breaths/minute
What is a normal temperature?
Less than 100 degrees F or 37.8 Celsius or less than 2 degrees F of baseline ( pre-Tx temperature reading)
