Documenting and Reporting in Nursing Practice Flashcards
1
Q
purpose of medical records
A
- communication
- legalities
- funding and resource management
- auditing and monitoring
- education
- care planning
- research
2
Q
Guidelines for documentation
A
- avoid pre-charting
- protect security of your password for computed documentation
- do not leave blank spaces or lines in a written nurses progress notes
- record all enteries legibly and in balck ink
- do not erase, apply correction fluid to, or scratch out errors made while recording
- if order is questioned, record that clarification is sought
- document only for yourself
- avoid using generalized empty phrases
- begin each entry with the date and tine and end with signiture and credentials
- do not document critical comments
- correct all errors promptly
- record all facts
- document as close as you can to the time of event
3
Q
not charted =
A
not done
4
Q
how long does the patient have to file a clain
A
2 years
5
Q
how long do lawyers have to serve the defendant
A
1 year after patient claim
6
Q
how long can the examination occur
A
up to one year
7
Q
trials can take ______ to complete
A
5-10 years
8
Q
good quality documentation includes
A
- facula
- accurate
- complete
- current
- organized
- complient with standards
9
Q
factual
A
- not vague
- no personal opinions
10
Q
accurate
A
- accurate information, correct spelling
- uses measurements when possible
11
Q
Complete
A
- appropriate and essential information
- include all interventions
12
Q
current
A
- chart on time, chart often
- use 24 hour clock
13
Q
organized
A
- take time to organize thoughts
- use specific organizational strategy
14
Q
Compliant with standards
A
- agency policies / procedures
- CARNA documentation guidelines
15
Q
ASH requirments for signitures
A
- Day (2 numbers), months (3 letters), year (four numbers) EXAMPLE: 22OCT 2019
- time: 24 hour clock
- signiture log must be signed if any documentation has been done on the patient
