Documentation Flashcards
(34 cards)
What is the Texas Administrative Code Title 22 Tx BON?
The standards that are applicable to ALL NURSES
Board of Nursing Tx expects all nurses to report and document which of the following? Select all that apply
- signs and symptoms
- what you did in the room
- meds and treatments (what you did for them)
- the pts response
- contacts with other health care workers
- relavent data
signs and symptoms
what you did in the room
meds and treatments (what you did for them)
the pts response
contacts with other healthcare workers
What does ANA stand for?
american nurses association
what are the ANA standards for documentation?
- relevant data
- problems and issues
- expected outcomes
- signs and symptoms
- standardized language, normal terminology
- implementation and any modifications
- coordination of care
- results of evaluation
- quality and performance improvement initiatives
relevant data
problems and issues
expected outcomes (as measurable goals; where you want the pt to be after the treatment)
standardized language
implementation and any modifications
coordination of care
results of evaluation
quality and performance improvement initiatives
What should the records contain?
- pt identification and demographic data
- informed consent for trtmnt and procedure
- admission data
- nursing problems
- care plans
- record of nursing care treatment and evaluation
- medical history
- medical diagnosis (dr’s)
- therapeutic orders
- progress notes
- physical assessment findings
- diagnostic study findings
- pt education
- summary of operations
- discharge plan and summary
- communication
pt id and demographic data
informed consent for trtmnt and procedure
admission data
nursing problems
care plans
record of nursing care trtmnt and eval
medical history
medical diagnosis
therapeutic orders
progress notes
physical assessment findings
diagnostic study findings
pt education
summary of operations
discharge plan and summary
when does discharge planning start?
discharge planning starts on admission
what is the purpose of records?
so that the nurse doesn’t get sued
if it isnt recorded, it never happened
which of these includes the purpose of records
- communication
- admission data
- legal document
- reimbursement compliance
- education
- research
- auditing and monitering
- continuity of care
communication
legal document
reimbursement compliance
education
research
auditing and monitering
continuity of care
What is communication in terms of nursing?
Multi disciplinary
Critical for continuity and risk reduction
Which of these help with nursing communication?
- current pt status/ needs
- pt progress
- pt therapies
- pt consultations
- pt education
- pt discharge planning
- how much they slept last night
current pt status
pt progress
pt therapies
pt consultations
pt education
pt discharge planning
What should documentation be?
- factual
- accurate
- complete
- current
- organized
- all of the above
ALL OF THE ABOVE
What did you feel?
What did you see?
What should the nurse NEVER do?
NEVER PUT AN ASSUMPTION OR OPINION IN THE CHART!!!
A factual document should be?
objective
descriptive
subjective (quotes)
An accurate documentation should be/have?
exact measurements
clear
understandable
standard abbreviations only
timed, dated with signature and title
CORRECT SPELLING
A complete document should have?
Condition change ( onset, duration,, location, description, precipitating factors, behaviors… )
DO NOT LEAVE BLANKS, USE N/A
Communication with patient and family
What is the whole picture for documenting/ charting?
anyone reviewing the chart must be able to understand an accurate, clear, and comprehensive picture of:
- pts needs ( what did you see )
- nurses interventions ( what did you do )
- pts outcome ( what was the outcome )
When should documentation start?
ASAP
time of occurance
use military time
NEVER PRE-TIME, PRE-DATE, PRE-CHART BC ITS ILLEGAL
Should the chart be organized
- chronological order
- clear
- concise
- to the point
- complete sentences not needed
Yes/ No
Yes
nurse dont need to type everything in detail, just needs to know what happened
Should the nurse avoid terms that’ll make them look incompetent?
Yes
Also the terms are assumption terms
What are examples of avoided terms?
- accidentally
- apparently
- APPEARS
- could be
- miscalculated
- somehow
- unintentionally
- NORMAL
- GOOD
- BAD
Which of these are some documentation don’ts?
- don’t document a pts problem without charting what you did about it
- dont alter, no white out or use an eraser
- dont use quotations
- dont chart ahead of time, its fraud
- dont chart what someone else heard, felt, or smelled, unless info is critical
- dont write imprecise descriptions; ie bed soaked, large amount
dont document pts problem without charting what you did about it
dont alter, no white out or use an eraser
dont chart ahead of time its fraud
dont chart what someone else heard, felt, or smelled, unless info is critical
dont write imprecise descriptions; ie, bed soaked, large amount,
What are some common formats of charting?
- Narrative
- Problem- Intervention - Evaluation (PIE)
- SOAP/ SOAPIE/ SOAPIER
- DAR
- Dhar Man
Narrative
Problem - Intervention - Evaluation (PIE)
SOAP/ SOAPIE/ SOAPIER
DAR
What does the nurse put down in a narrative format?
written in order of pt experience
provides details of pts care, status, activities, nursing interventions, psychological context and response to trtmnt
What does PIE stand for?
Problem - Intervention - Evaluation
nursing focused instead of medical focused and eliminates need for separate care plan
