Documentation

Question 1

TX Administrative Code Title 22 TBON

Answer 1

Accurate and complete report and documentation
including
-client’s status with signs and symptoms
-nursing care rendered
-administration of meds and history
-client’s response
-contacts with other healthcare team members concerns significant events for pt

Question 2

ANA Standards for Documentation

Answer 2

-relevant data accurately and accessible to the interprofessional team
-problems and issues shows the determination of expected outcomes and plans
-expected outcomes in measurable goal
-standardized language or recognized terms
-implementing and modifications of care plan
-coordination of care
-evaluation
-quality and performances improvement initiatives through studies and research

Question 3

Signs of a pt

Answer 3

what you see

Question 4

Symptoms of a pt

Answer 4

subjective to pt

Question 5

Records of a pt contain

Answer 5

identification and demographics, consent
admission data
care plans and notes
medications and orders
labs, assessments, a summary of operations
education
discharge plans

Question 6

Purpose of Records

Answer 6

communication
legal doc
reimbursement compliance
education research
auditing and monitoring

Question 7

Fill in the Blank
The chart is a _______ _______ because it is the description of the facts at the time.

Answer 7

persuasive witness

Question 8

Communication

Answer 8

multi-disciplinary
critical for continuity and risk reduction (current status and needs, progress, therapies, consultations, education, and discharge planning

Question 9

Documentation needs to have ALL of these …

Answer 9

Accurate
Bias-free
Complete
Detailed current
Easy to read and understand
Factual
Harmless (legally)
Organized

Question 10

Objective

Answer 10

observed data by the nurse

Question 11

Descriptive

Answer 11

smelled, tasted

Question 12

Subjective

Answer 12

statement from the patient

Question 13

Pain is _________ with no assumptions or opinions.

Answer 13

subjective

Question 14

Which of these documentation statements are incorrect?

-I found the patient on the floor
-Patient said they fell on the floor.
-I heard a thud and found pt on the floor
-Patient fell out of bed again!

Answer 14

Patient fell out of bed again

Question 15

How should an entry be signed off?

Answer 15

time, dated with signature and title

Question 16

Accurate data needs to have

Answer 16

exact measurements
clear
understandable
standard abbreviations only
correct spelling
time, dated with name and title

Question 17

Complete data needs to include

Answer 17

condition changes (onset, duration, location, description, precipitating factors, and behaviors)
no blanks only N/A
Communicate with pt’s family for other info

Question 18

________ reviewing the chart needs to be able to understand an accurate, clear, and comprehensive picture of the needs, interventions, and outcomes.

Answer 18

Anyone

Question 19

You should _______ predate, pre time, prechart; data because it is _____ ________ of a record

Answer 19

Never; illegal falsification

Question 20

Do you need complete sentences when charting data?

Answer 20

no

Question 21

What terms should you avoid when charting

Answer 21

Accidentally, apparently, appears, assume, confusing, could/may be, miscalculated, mistake, somehow, unintentionally, normal, good, bad

Question 22

T/F:
You should never document a pt without charting what you did about it.

Answer 22

true

Question 23

T/F:
You should alter a pt record and it is not a crime

Answer 23

false, major crime

Question 24

T/F: It is okay to write imprecise descriptions such as the bed was soaked, or a large amount of the urine was on the floor.

Answer 24

false

Question 25

T/F: It is not okay to write about what someone else heard, felt, or smelled unless the information is critical.

Answer 25

true

Question 26

What are some common formats of documentation

Answer 26

Narrative Problem-Intervention-Evaluation (PIE) SOAP/SOAPIE/SOAPIER DAR MAR Kardex

Question 27

Narrative documentation

Answer 27

written in order of pt experience happens provides details of care, status, activities, interventions, psychosocial context, and pt's responses

Question 28

Charting by exception is also known as

Answer 28

shorthand notes

Question 29

PIE

Answer 29

nursing focused onstead of medical focused and eliminates need for separate care plan

Question 30

SOAP/SOAPIE/SOAPIER

Answer 30

Subjective Objective Assessment Plan Intervention Evaulation Revision

Question 31

DAR

Answer 31

data, action, reponse nursing admission data forms discharge summary flow sheets and graphic sheets checklist, assessment, vs, I&O

Question 32

MAR

Answer 32

Medication Admission Record scheduled meds, unscheduled meds, allergies, and single orders

Question 33

Kardex

Answer 33

summary of pt's needs and care worksheet reference of basic info not a part of the record containing pt's data, meds by priority, allergies, orders

Question 34

Is Kardex a permanent record?

Answer 34

no

Question 35

What color of pen should you write within nursing on paper charts?

Answer 35

black/ blue in print never use white out, erasable pen, no pencil

Question 36

What color of the pen should you write within nursing on paper charts?

Answer 36

black/ blue in print never use white out, erasable pen, no pencil

Question 37

Flow sheets

Answer 37

colums for data with date and times

Question 38

Nurse Progress Notes

Answer 38

pt's condition, problems, and complaints interventions responses achieve outcomes additional assessments report hand offs

Question 39

Should you always document when you hand off your patient and resume taking care of a pt?

Answer 39

yes

Question 40

In nursing clinicals, it is important when documenting to?

Answer 40

be confidential and comply with HIPPA no sharing info no med record access EAR traceable no identifiers on paperwork

Question 41

Good components of a document record needs

Answer 41

who what (assessment findings, complaints, and care provided) when (time of provided care) where (place given meds) how (treatment completed, response) outcome followups accuracy (exact measurements)

Question 42

Information needed to notify providers?

Answer 42

Full name and title exact time notified state specific lab results, symptoms, or other assessments record response order given include other info commitment for followup symptoms note own actions when assisting physician

Question 43

If the physician does not answer,

Answer 43

pursue the chain of command notify direct supervisor record all actions

Question 44

Should you use describtive language of what a pt did or label them?

Answer 44

descriptive language document refusal and reason why statement

Question 45

Care not documented is

Answer 45

care that was not provided

Question 46

What are common mistakes that lead to legal actions

Answer 46

Fail to record health info/drugs Fail to record nursing actions Fail to record meds given Fail to record response Fail to write legibly or complete Fail to document D/C or refusal of meds Fail to notify healthcare teams Fail to record late entries correctly Fail to record referrals Fail to record teachings

Question 47

How do you correct an error on a report?

Answer 47

single line through with initials On EMR -make new entry and explain error