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IM 1 > Documentation- Exam 3 > Flashcards

Documentation- Exam 3 Flashcards

1
Q

Relevant data

A

Accurately and in a manner accessible to the interprofessional team

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2
Q

Problems and issues

A

In a manner that facilitates the determination of the expected outcomes and plan

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3
Q

Expected outcomes as..

A

Measurable goals

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4
Q

Discharge happens when

A

On admission

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5
Q

Purpose of records

A

Communication
Legal document
Reimbursement compliance
Education
Research
Auditing and monitoring
Continuity of care

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6
Q

Communication

A

Critical for continuity and risk reduction
- current status/ needs
- progress
- therapies
- consultations
- education
- discharge planning

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7
Q

Documentation needs to be

A

Factual
Accurate
Complete
Current
Organized

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8
Q

You need to be what on documentation

A

Objective
Descriptive
Subjective (quotes)
NO ASSUMPTIONS

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9
Q

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

A

Patient needs
Nurses interventions
Patient outcome

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10
Q

When to document

A

As soon as possible
Time or occurrence
Never pre-time

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11
Q

Documentation needs to be in

A

Chronological order
Clear
Concise
To the point
Complete sentences not needed

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12
Q

Avoid these terms

A

Accidentally
Apparently
Appears
Assume
Confusing
Could be
May be
Miscalculated
Mistake
Somehow
Unintentionally
Normal
Good
Bad

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13
Q

Documentation don’ts

A

-Don’t document a patient problem without charting what you did about it
-Don’t alter a pts record
- don’t write imprecise descriptions
- don’t chart what someone else heard
- don’t chart ahead of time

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14
Q

Narrative

A

Written in order of patient experience happens
Provides details in patients care, status, activities, nursing interventions, psychological context and response to treatment

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15
Q

Problem-intervention-evaluation (PIE)

A

Nursing focused instead of medical focused and elongated need to separate care plan

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16
Q

Soap/soapie/soapier

A

Subjective data, objective data, assessment, plan, intervention, evaluation, revision

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17
Q

DAR

A

Data, action, response

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18
Q

Flow sheets

A

Check list - assessment
Vital signs
Intake and output

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19
Q

Medication administration record

A

Scheduled meds
Unscheduled meds
Drug allergies
Single order medications

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20
Q

Kardex

A

Not a permanent record
A summary of pts needs and care

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21
Q

Paper charts

A

Print or cursive
Blue or black ink
Never use white out
Never use erasable ink
Never obliterate
Never erase - no pencils

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22
Q

SBAR

A

Situation
Background
Assessment
Recommendation

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23
Q

Nurses progress
Notes / narrative

A

Patients condition, problems, and complaints
Interventions
Patients response to interventions
Achievement of outcomes
Additional assessment
Report given
Time
Nurses name
Important information

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24
Q

Components of good documentation

A

Who, what, when, where, how, outcome

25
Who
The patient
26
What
Assessment findings Patients condition Care you provided
27
When
The time when you provided care
28
Where
Where did event take place Where was the treatment given or medication administered
29
How
How was treatment completed How did the resident tolerate the procedure/ treatment
30
Outcome
Outcome of the procedure / treatment
31
Follow up
What type of follow up needed
32
Accuracy
Exact measurement
33
Specific aspects of care
Fall reduction Infection prevention Non-conforming and management Pain assessment and management Restraints Skin care Suicide
34
Notifying provider Include
Include the full name of the provider
35
Notifying provider - note
Note the exact time that you notified provider
36
Notifying provider -state
State the specific laboratory result, symptom, or other assessment data that you reported
37
Notifying provider - record
Record the providers response, using exact words if possible
38
Notifying provider- include
Any order the provider gives or when they don’t give orders
39
Notifying provider- pursue
If a provider fails to respond to a page, a telephone message, or fails to order an intervention
40
Notifying provider - record
Record all your actions
41
Documentation - Never
Never use to describe a patient or patients behavior ex: obnoxious
42
Correct documentation
Correct all errors promptly, using the correct method
43
Record
Record all facts, do not enter personal opinions If a order was questioned, record that clarification was sought
44
Chart
Chart only for yourself and not for others
45
Keep
Keep your computer password secure
46
Avoid
Avoid generalizations
47
Paper charting
Begin each entry with the date/time and end with your signature and title
48
Correcting errors
A single line through entry and your initials EMR- new entry , explain error Make sure you have the right chart!!
49
Late entry
Paper chart- add the entry to the first available line, and label it late entry to indicate that it’s out of sequence, according to facility policy EMR- change date and time and then document
50
Standards applicable to all nurses
Accurately and completely report and document Client status including signs and symptoms Nursing care rendered Administration of medication and treatments Clients responses Contacts with other healthcare team members concerning significant events regarding clients status
51
Records contain
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
52
Purpose of records
Communication Legal document Reimbursement compliance Education Research Auditing and monitoring Continuing of care
53
Documentation
Factual Accurate Complete Current Organized
54
Subjective
Quotes from patient
55
Anyone reviewing the chart must be able to understand an accurate, clear and comprehensive picture of
Patient’s needs Nursing interventions Patient outcome
56
Documentation needs to be in
Chronological order Clear Concise To the point Complete sentence is not needed
57
Documentation Donts
Don’t document a patient problem without charging what you did about it Don’t alter patient’s record Don’t write, imprecise descriptions, such as bed soaked Don’t chart what someone else heard felt or smelled unless information is critical Don’t chart ahead of time
58
Paper charts
Print or cursive Blue or black ink Never use white out Never erase

IM 1 (34 decks)

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