Documentation part 1 Flashcards

(38 cards)

1
Q

What is documentation?

A

any written or electronically generated information about a client that describes the care or service provided to that client

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2
Q

What are the 6 purposes of pt. records?

A

COMMUNICATION & CARE PLANNING

LEGAL DOCCUMENTATION

EDUCATION

FUNDING & RESOURCE MANAGEMENT

RESEARCH

QUALITY REVIEW

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3
Q

How does documentation improve communication and care planning?

A
  • All health care members communicate pt needs, progress, care, tx, and education
  • ensures consistency and continuity of care
  • provides baseline data
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4
Q

What does documentation do in terms of the benefit of being a legal document?

A
  • demonstrates accountability
  • best defense against legal claims
  • care not documented is care not given
  • need to document assessments, care, pt. responses, instructions, referrals
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5
Q

What is the purpose of documentation in terms of education?

A
  • nurses/students can learn about illness and patterns of behaviour
  • enables student to see patterns and types of care provided/needed
  • helps to understand the uniqueness of each pt.
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6
Q

What is the purpose of documentation in terms of funding and resource management?

A
  • shows how HC resources have been used

- level of acuity of pt indicates the type and of resources required

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7
Q

What is the purpose of documentation in terms of research?

A
  • provides data for statistical purposes

- analysis of data for research purposes

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8
Q

what is the purpose of documentation in terms of quality review?

A
  • evaluation of the quality and appropriateness of care
  • audit chart after discharge or while pt is in hospital
  • allows other disciplines to work together
  • deficiencies are shared and results in change of practice/policies
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9
Q

what are the 6 guidelines for quality documentation?

A

1) Factual information
2) Accurate
3) Complete
4) Current
5) Organized
6) complies with standards

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10
Q

What should you ensure your documentation is like to be factual?

A

descriptive, objective

non-judgmental

no inferences without supporting data

avoid: appears, seems, apparently

Subjective data needs to have quotations and be as exact as possible

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11
Q

What should you ensure your documentation is like to be accurate?

A

accurate and specific time, amount, size, description, response

spelling

initials/signature and status after each timed charting entry

if there is an error, signal line through it, above “charting error” and initials

“Late entry” addendum to note of Jan. 13/12

any blank spaces need to have a line through them

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12
Q

What does telegraphic mean?

A

certain words may be omitted to allow quick and rapid transmission

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13
Q

What are some abbreviations to avoid?

A

U, IU, abbreviated drug names, @

QD or OD use daily

QOD use every other day

OS, OD, OU write it out

D/C use discharge

< and > use words

NEVER use 0 by itself after a decimal

ALWAYS use 0 before a decimal (0.5 not .5)

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14
Q

How can you ensure your documentation is complete?

A

make sure it includes all of the pt’s status, care given and response to care

ensure appropriateness

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15
Q

What does it mean to have current documentation?

A

timely entries

make sure data is recorded at time of occurrence (never before hand) ex med admin, tx’s, prep for tests/surgery, change in status, admission, death

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16
Q

What factors contribute to the frequency of documentation needed?

A

Acuity
Complexity
Variability

these all inc the freq

17
Q

What are some of the standards documentation must meet?

A

each pg has pt. name and ID #

date of data entry on each page, include new date if it changes

include a time with ever newly timed entry

signature/initials and status of recorder with every timed entry

18
Q

What is documentation by inclusion?

A

done by ongoing/regular basis

makes note of all assessment findings, interventions and client outcomes

19
Q

What is documentation by exception?

A

Notes only the negative findings that vary from the norm.

Requires the facility to have detailed policies defining the norm

20
Q

What is narrative charting?

A

most traditional

includes care given, observations, pt responses

is in chronological/care format

21
Q

What are the disadvantages of narrative charting?

A

lengthy and cluttered

little structure if no documentation guidelines

information becomes scattered throughout the chart

time consuming

22
Q

What does the acronym SOAP or SOAPIER stand for related to charting

A
S ubjective data
O bjective data
A sessments
P lan
I mplementation
E valuation
R evision
23
Q

What is the SOAP or SOAPIER type of charting?

A

type of problem oriented charting

charting is relation to specific patient problems

POMR/ADIE are variations of this

24
Q

What are the disadvantages for SOAP or SOAPIER charting

A

some overlaps

hard to get all disciplines using the same format

25
What is focus charting?
It is a column format for charting pt. concern identified/key words identified (ex pain, agitation) includes subjective and objective data TWO TYPES DARE AND DARP
26
What does DARE stand for?
it is used in focused charting D ata A ction (present/future) R esponse E xpected outcome(s) expected outcomes ex pt will have a temperature of 37C by 1800 hrs
27
What deos Darp stand for?
Used for focused charting D ata A ction (present) R esponse P lan (future actions) plan ex assess TPR q 4h for 24 hours
28
What are the advantages of focus charting?
dec charting time patient centered notes inc usefulness in a clinical setting problem identified/resolution clearly documented
29
What is the disadvantage of focus charting?
it is easy to switch to narrative charting due to fitting information in under appropriate sections
30
What is charting by exemption (CBE)?
chart only exception to the rule (significant/abnormal data) several components to this system - flow sheets - standards of practice - standard care plans
31
What is the advantage of charting by exemption?
forms kept at pt's bedside therefore no need for transcription and therefore time saving
32
What is the disadvantage of charting by exemption?
Staff education/accountability need to be intimately familiar with the defined policies to understand what should and should not be charted
33
What are some examples of permanent documentation tools?
flow sheets fluid balance records checklists
34
What are some advantages of documentation by permanent documentation tools
helps with routine care time saver ensures systematic assessment is comprehensive (greatest amount of info in one area)
35
What is the disadvantage of documenting by permanent documentation tools?
some duplication possible
36
What are care maps/care paths?
maybe multidisciplinary standardized plan for care has expected outcomes with time frame uses several components: - focus charting for variance - sample signature sheet
37
What are the advantages of care maps/care paths?
reduces duplication and amount of charting reduces amount of time charting
38
What is the disadvantage of care maps/care paths?
only includes variations for specific health issues/situations