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CSON IM1 > EXAM 3- Documentation > Flashcards

EXAM 3- Documentation Flashcards

1
Q

what should you accurately & completely document routinely as a nurse?

A
  • pt status - including s/s
  • nursing care
  • medication & treatment administration
  • pt response to interventions
  • any contact with health care team members concerning significant events (CN, provider, PT, RT, chaplain, etc)
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2
Q

what’s the difference between signs & symptoms?

A
  • signs- objective, observable
  • symptoms- subjective (what the pt tells you)
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3
Q

examples of treatments as nursing interventions

A
  • nursing care
  • ambulation
  • TCDB
  • wounds care
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4
Q

ANA standards for documentation

A
  • relevant data- accurately & accessible to the team
  • problems & issues- facilitates determination of the expected outcomes/plan
  • expected outcomes- measurable goals (decrease pain level from an 8 to a 3)
  • plan uses standard language/ terms
  • implementation & modifications- including changes of the plan (put the plan into action)
  • coordination of care
  • results/evaluation
  • quality & performance improvement- involved in nursing practice
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5
Q

what do formal pt records contain?

A
  • pt identification & demographic data, medication hx
  • admission data, discharge plan
  • informed consent, pt education, summary of operations
  • nursing diagnoses/ problems, care plans, treatment & evaluation, physical assessment
  • medical diagnosis, therapeutic orders, diagnostic study
  • progress notes
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6
Q

what are some purposes of pt records?

A
  • communication
  • legal document
  • reimbursement compliance
  • educaiton/ research
  • auditing/ monitoring
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7
Q

is the pt chart a persuasive witness/ read as a legal document?

A

yes
it is a description of the facts at the time

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8
Q

why are charts important for communication?

A

allows for continutity & risk reduction between multi-disciplinary teams

nursing, medicine, PT, etc

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9
Q

components of proper documentation

5

A
  • factual
  • accurate
  • complete
  • current
  • organized
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10
Q

how can you keep your documentation factual?

A
  • objective
  • descriptive
  • subjective (quotes) from pt or family

just the facts

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11
Q

you heard a thud and went to the room & found pt on the floor. what should you document?

A. RN heard a thud and found the pt lying on the floor. it appears the pt has fallen while getting out of bed
B. pt fell in room, event was not observed by staff
C. RN heard a thud, went to the room & found pt lying on floor in room
D. RN found pt on floor and assumes the pt’s family member neglected to help them up

A

C
always document exacly what happened, NEVER ASSUME

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12
Q

how can you document accurately?

A
  • use exact measurements
  • clear
  • understandable
  • standard abbreviations only
  • time, date, signature, title
  • spelling
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13
Q

how can you document completely?

A
  • condition change (onset, duration, location (PQRST), description, precipitating factors, behaviors)
  • do not leave blanks (use N/A or lines)
  • communication with pt & family (document the ed. you gave, as well as their repsonse (agreement/disagreement))
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14
Q

what should the chart ultimately reveal?

A
  • pt needs
  • nurse’s interventions
  • pt outcome
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15
Q

how can you keep your documenting current?

A
  • chart as soon as possible/ at the time of occurrence
  • use military time
  • never pre-chart (illegal falsiication)
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16
Q

how can you keep your documenting organized?

A
  • chronological order
  • concise, clear, to the point
  • complete sentences not needed
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17
Q

terms to avoid in charting

A

accidentally apparently appears assume confusing could be may be miscalculated mistake somehow unintentionally normal good bad

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18
Q

fix the error:

pt has normal lung sounds

A

lung sounds clear bilaterally

avoid using the word “normal”, be desrcriptive

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19
Q

true or false

you can document a pt problem as long as you plan on charting your intervention later on

A

don’t document a pt problem w/o charting what you did about it

false

20
Q

true or false

altering a pt record is a crime

A

true

21
Q

true or false

you should avoid writing imprecise descriptions (bed soaked, large amount, etc)

A

true

22
Q

true or false

you can document what someone else heard, felt, or smelled if they tell you the exact information of the occurrence

A

don’t chart what someone else heard, felt, or smelled unless the information is critical

use quotations appropriately

false

23
Q

narrative documentation

A
  • written in order of pt exerience
  • provides details of pt care, status, activies, nursing interventions, psychosocial context, & response to treatment
  • charting by exception
24
Q

PIE

A
  • Problem
  • I-ntervention
  • Evaluation

nursing focused (rather than medical focused) and eliminates need for separate care plan

25
Q

SOAP/SOAPIE/SOAPIER

A
  • S- subjective data
  • O- objective data
  • A- assessment
  • P- plan
  • I- intervention
  • E- evaluation
  • R- revision
26
Q

DAR

A
  • Data
  • Action
  • Response
27
Q

what types of forms would be on a flow sheet?

A
  • vital signs
  • assessment check list
  • I/O
28
Q

medication administration records (MAR)

A
  • scheduled meds
  • unscheduled meds
  • drug allergies
  • single order meds
29
Q

kardex

A

summary of pt needs & care

  • pt data (name, age, marital status, religion, physician, family contact
  • medical diagnoses listed by priority
  • allergies
  • medical orders
  • activities permitted

NOT. a part of permanent record

30
Q

what should you use to write a paper chart?

A
  • blue or black ink
  • no white out/ erasable pens
31
Q

is the kardex a part of the permanent record?

A

no

32
Q

SBAR

A
  • Situation
  • Background
  • Assessment
  • Recommendation
33
Q

what do nurse’s notes contain?

A
  • pt condition, problems, & complains
  • interventions
  • pt response to interventions
  • achievement of outcomes
  • additional assessment
  • report given/received (nurse’s name, time, important information)
34
Q

should you document when you give/ receive report?

A

YES!!

include the nurse’s name, time, any important information

35
Q

components of good documentation

A
  • who
  • what (assessment findings, cc, care provided)
  • when (when you provided care)
  • where (where did the event/tx take place)
  • how (how was tx completed, how did pt respond/tolerate)
  • outcome (outcome of procedure, tx)
  • follow-up (what f/u is needed, vitals, pain level, etc)
  • accuracy (exact measurements)
  • objective vs subjective data
36
Q

what should you document when notifying a provider?

A
  • full name of provider
  • exact time of notification
  • specific lab result, symptom, or assessment data
  • provider’s response
  • any orders the provider gives
  • vitals, observations, nursing interventions
  • f/u by provider
  • symptoms & parameters
  • note your own actions to assist pt
  • pursue chain of command if provider doesn’t answer
  • record all your actions
37
Q

what should you include when documenting a pt’s refusal?

A

document:
* pt refusal
* reason for refusal
* what you did about it

38
Q

true or false

you should NEVER use labels to describe a pt or their behavior

A

true

39
Q

be more desrciptive

wound is infected

A
  • skin around wound is red
  • warm to touch
  • purulent disharge
  • pt complains of increased paid x1 day
40
Q

be more descriptive

pt is nervous

A

pt asked several times about length of hospitalization, discomfort, and time off work

41
Q

what should you document if you question a provider’s order?

A

document that clarification was sought

42
Q

how do you correct an error on a paper chart? on EMR?

A
  • single line through entry, write your initials
  • EMR: make a new entry, explain the error
43
Q

how should you chart a late entry in a paper chart? EMR?

A
  • paper: add entry and title “late entry”, record the date/time of the entry & the date/time it should have been made
  • EMR: change date/time & document (this can be tracked/audited)
44
Q

be more descriptive

1900 pt arrived to ER complaining of stomach pain

A

include PQRST to describe pain more accurately

45
Q

what % of the most frequent allegations against nurses in medical liability claims deal with documentation?

A

66%

46
Q

why do nurses commonly have claims made against them concerning documentation?

A
  • ascence of documentation- if it wasnt charted, it wasnt done
  • timing of documentation- (late entries) self servind, different that what would ahve been charted at the time of tx

CSON IM1 (15 decks)

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