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Documentation Flashcards

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1
Q

Standards Applicable to All Nurses

A

Accurately and completely report and document:
-Client’s status including signs and symptoms
-Nursing care rendered
-Administration of medications and treatments
-Client’s response(s): and
-Contacts with other health care team members concerning significant events regarding client’s status

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2
Q

Document Relevant data

A

accurately and in a manner accessible to the interprofessional team.

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3
Q

Document Problems and Issues

A

in a manner that facilitates the determination of the expected outcomes and plan.

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4
Q

Document Expected outcomes

A

as measurable goals

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5
Q

Document The Plan

A

using standardized language or recognized terminology

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6
Q

Document Implementation and

A

any modifications, including changes or omissions, of the identified plan

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7
Q

Document The Coordination of

A

Care

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8
Q

Document The Results of the

A

evaluation

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9
Q

Document Nursing Practice in

A

a manner that supports quality and performance improvement initiatives.

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10
Q

Patient Records Contain

A

-Patient identification and demographic data
-Informed consent for treatment and procedures
-Admission data
-Nursing diagnoses or problems
-Care plans
-Record of nursing care treatment and evaluation
-Medical History
-Medical Diagnosis
-Therapeutic Orders
-Progress notes
-Physical assessment findings
-Diagnostic study findings
-Patient education
-Summary of operations
-Discharge plan and summary

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11
Q

The Purpose of Records Includes

A

Communication
Legal document
Reimbursement compliance
Education
Research
Auditing and monitoring Supports compliance with standards of care

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12
Q

The chart is a very persuasive witness because

A

it is the description of the facts at the time

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13
Q

Communication is

A
  • Multi-Disciplinary
    -Critical for Continuity and Risk Reduction
    current status/ needs
    progress
    therapies
    consultations
    education
    discharge planning
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14
Q

Documentation must be

A

-Factual

-Accurate

-Complete

-Current

-Organized

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15
Q

Factual documentation is

A

Objective
Descriptive
Subjective (quotes)

NO ASSUMPTIONS OR OPINIONS

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16
Q

Accurate documentation is/has

A

Exact measurements
Clear
Understandable
Standard Abbreviations only
Timed, dated with signature and title
Correct spelling

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17
Q

Complete documentation

A

-Condition change
Onset, duration, location, description, precipitating factors, behaviors
-Do not leave blanks. Use N/A
-Communication with patient and family

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18
Q

Anyone reviewing the chart must be able to understand an accurate, clear and comprehensive picture of

A

-Patient’s needs
-Nurse’s interventions
-Patient outcome

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19
Q

Current documentation

A

-As soon as possible
-Time of occurrence
-Military clock
-Never pre-time,Pre-date, pre-chart. (this is illegal falsification of the record)

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20
Q

1pm

A

1300

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21
Q

2pm

A

1400

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22
Q

3pm

A

1500

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23
Q

4pm

A

1600

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24
Q

5pm

A

1700

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25
6pm
1800
26
7pm
1900
27
8pm
2000
28
9pm
2100
29
10pm
2200
30
11pm
2300
31
12am end of day (midnight)
2400
32
12am begging of day
0000
33
Organized documentation
Chronological order Concise Clear To the Point Complete sentences not needed
34
Terms to Avoid
Accidentally Apparently Appears Assume Confusing Could be May be Miscalculated Mistake Somehow Unintentionally Normal Good Bad
35
Documentation “Don’ts”
-Don’t document a patient problem without charting what you did about it. -Don’t alter a patient’s record – this is a crime. -Don’t write imprecise descriptions, such as bed soaked, large amount… -Don’t chart what someone else heard, felt or smelled unless information is critical. Use quotations and attribute remarks appropriately. -Don’t chart care ahead of time. It’s fraud.
36
Narrative
-written in order of patient experience happens. -Provides details of patient’s care, status, activities, nursing interventions, psychosocial context and response to treatment. Charting by Exception
37
Problem-Intervention-Evaluation (PIE)
Nursing focused instead of medical focused and eliminates need for separate care plan
38
SOAP/SOAPIE/SOAPIER
S - Subjective data O - objective data A - assessment P - plan I - intervention E - evaluation R - revision.
39
DAR
D - Data A - Action R - Response
40
Forms
-Nursing admission data forms -Discharge summary -Flow sheets and graphic sheets -Medication Administration Records -Kardex
41
Flow sheets and graphic sheets
-Check list - assessment -Vital signs -Intake and Output
42
Medication Administration Records
Scheduled meds unscheduled meds drug allergies single order medications
43
Kardex
Not a permanent record. A summary of patient needs and care. Usually Contains: - Patient’s data (name, age, marital status, religious preference, physician, family contact). - Medical diagnoses: listed by priority. - Allergies. - Medical orders (diet, IV therapy, etc.). - Activities permitted.
44
Rules For Paper Charts
- Print or Script - BLUE or BLACK Ink - NEVER Use White-Out - NEVER Use Erasable Ink - NEVER Obliterate - NEVER erase – NO Pencils
45
Flow Sheets/Forms
Vertical or horizontal columns for recording dates and times and related assessment and intervention information: - Vital Signs - Intake and Output - Assessment
46
Nurse’s Progress Notes/Narrative
Patient’s condition, problems, and complaints. Interventions. Patient’s response to interventions. Achievement of outcomes. Additional assessment ***Report given, and report received Time Nurse’s name Important information
47
As a STUDENT in Clinical
Confidentiality and compliance with HIPPA are part of your practice -Do not share information with classmates unless in clinical conference -Do not access medical records of other patients -Electronic health records are traceable through login -CAN cause disciplinary action by employers and dismissal from work or nursing school
48
Students paperwork in clinical practice should not include
patient identifiers Ex. Room number, DOB, demographic information, name
49
Components of Good Documentation
Who What When Where How Outcome
50
What
Assessment findings? Patient’s complaint Care you provided
51
When
The time when you provided care
52
Where
Where did event take place Where was the treatment given or medication administered
53
How
How was treatment completed? How did the resident tolerate the procedure/treatment
54
Outcome
Outcome of the procedure/treatment
55
Follow-up
What type of follow-up needed (retaking BP. Pain level…)
56
Accuracy
Exact measurements (don’t use about or approximately
57
Specific Aspects of Care
-Critical diagnostic results -Fall reduction -Infection prevention -Medications and reconciliation of medications -Non-conforming patient behavior -Pain assessment and management -Patient and family role in safety -Restraints -Skin care -Suicide
58
Notifiying the Provider
INCLUDE the full name of the provider. NOTE the exact time that you notified the provider STATE the specific laboratory result, symptom, or other assessment data that you reported. RECORD the provider’s response, using exact words if possible. INCLUDE any orders which the provider gives. If the provider gives no orders, note this - especially if you anticipated an order. For example, “Dr. Sara Jones informed of oral temperature of 104o F. No orders received.” In your complete note of the event, include the patient’s other vital signs, relevant observations and any nursing interventions you performed
59
Notifying the Provider Continued
Include the commitment for necessary follow-up by provider, such as, “Will visit patient at 0600.” Include symptoms and parameters such as changes in vital signs, level of consciousness, or pain that the provider defines as indicators for nurses to use in deciding to call the provider again. It is essential that you note your own actions to assist the patient in addition to documenting your contacts with the provider. If a provider fails to respond to a page, a telephone message, or fails to order an intervention and thereby creates a risk for the patient, pursue the chain-of-command and notify your direct supervisor. Record all your actions.
60
Never use labels to
describe a patient or patient’s behavior - ex: Obnoxious, belligerent, rude…
61
Instead of labels
Describe patient’s behavior
62
Document Patients rufusal,
reason for refusal and what you did about it.
63
Correct
all errors promptly, using the correct method.
64
Record
all facts; do not enter personal opinions
65
If an order was questioned
record that clarification was sought
66
Chart only for
yourself, not for others.
67
Keep your computer password
secure.
68
Avoid
generalizations.
69
Rules for Paper Charting
Begin each entry with the date/time and end with your signature and title. Do not leave blank spaces in nurses’ notes Write legibly in permanent black/blue ink.
70
Accurate documentation is the best defense for
legal claims
71
Must describe exactly what happened to patient and how nurse followed
agency standards
72
Try to chart
immediately following care provided
73
Care Not Documented is
CARE THAT WAS NOT PROVIDED
74
Common Mistakes requiring Legal Action
Failing to record health information/drugs Failing to record nursing actions Failing to record medications that was given Failing to record drug reactions/ or change in patient condition Failing to write legibly or complete Failing to document discontinued/refusal medication Failing to notify Dr., nurse, family and recording exact conversation Failing to record a late entry correctly Failing to record referrals Failing to record patient teaching
75
Correct Errors in a paper chart
using a single line through entry and your initials (no erasing, “white out”- do not write error or mistake) Make sure you have the right chart!!
76
Correct Errors in EMR
new entry. Explain error. Make sure you have the right chart!!
77
For a Late Entry in a Paper Chart
-Add the entry to the first available line, and label it “late entry” to indicate that its out of sequence, according to facility policy -Record the date and time of the entry and, in the body of the entry, record the date and time it should have been made
78
For a Late Entry in an EMR
change date and time and then document. However…
79
Overall, Documentations SHOULD be
-Accurate -Bias-free -Complete -Detailed -Current -Organized -Easy to read and understand -Factual -Harmless (legally)
80
Two out of three most frequent allegations against nurses in medical liability claims deal with
Documentation: either absence of documentation (NOT CHARTED = NOT DONE) or Timing of Documentation (Late entries)

CSON (5 decks)

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