Guidelines/Protocols & Tools in Documentation

Question 1

Serves as a communication tool. Captures patient data, clinical decisions, interventions, and patient responses.

Answer 1

Documentation

Question 2

FORMS OF Documentation

Answer 2

Electronic
Paper
Hybrid Formats

Question 3

The Documentation must have all care provided, included:

Answer 3

(A) Assessment Data
(N) Nursing Problems or Diagnoses
(I) Interventions
(E) Evaluation of Patient Responses

Question 4

Documentation Shows:

Answer 4

(F&TC) Frequency & Type of Care
(NA) Nursing Accountability
(PP&O) Patient Progress & Outcome

Question 4

Four of the preventable adverse events are considered “nurse-sensitive”:

Answer 4

Stage 3 or 4 pressure injuries
Falls with injury
Catheter-associated urinary tract infections (CAUTIs)
Central line–associated bloodstream infections (CLABSIs)

Question 5

Health records used for education/research must follow:

Answer 5

Privacy Laws
Ethical Standards

Question 6

EHR’s Stands for:

Answer 6

Electronic Health Records

Question 7

EMR’s Stands for:

Answer 7

Electronic Medical Records

Question 8

This type of record is: the scope is lifetime, supports longitudinal care, multi-user/real-time access, & broader clinical and public health use.

Answer 8

Electronic Health Records (EHR’s)

Question 9

This type of record is a one specific episode, focus on a single event, limited to a specific site, & good for internal recordkeeping.

Answer 9

Electronic Medical Records (EMR’s)

Question 10

This is a government initiative which set the goal for all healthcare records to be electronic by 2014.

Answer 10

American Recovery and Reinvestment Act (ARRA, 2009)

Question 11

This act is part of ARRA, promotes meaningful use of health IT and it’d goal is to improve care quality, safety, efficiency, and patient involvement.

Answer 11

HITECH Act (2011)

Question 12

FDAR stands for:

Answer 12

Focus, Data, Action, and Response

Question 13

UNIQUE FEATURE OF EHRS

Answer 13

• Combines all patient info into a single record.
• Stores diagnostic results (e.g., x-rays, ultrasounds).
• Allows analysis of patient data to:
  ⚬ Identify quality issues.
  ⚬ Link care to outcomes.
  ⚬ Supportevidence-baseddecisions.
• Document symptom progression
• Maintain thorough records of health
  teaching
• Track patient responses to interventions
• Promotes safer, more coordinated care
  across settings

Question 14

Use objective, clear, and descriptive information.

Answer 14

Factual

Question 15

Use exact measurements. Be concise and relevant—avoid unnecessary details.

Answer 15

Accurate

Question 16

What time does a nurse use/follow?

Answer 16

Military Time

Question 17

Keep entries concise, clear, and logical.

Answer 17

Organized

Question 18

Include essential and relevant information for patient care. Follow institutional policies and professional standards.

Answer 18

Complete

Question 19

Use only approved abbreviations—avoid
those on the TJC “Do Not Use” list.

Answer 19

True

Question 20

If using initials, include full name at
least once in the record.

Answer 20

True

Question 21

Used by health care team members to track a patient’s progress toward resolving health problems. Provides a chronological record of patient condition, interventions, and outcomes.

Answer 21

Progress Notes

Question 22

What are the types of progress notes?

Answer 22

Narrative
DAR/Focus Charting
Soap Notes
Pie Notes

Question 23

Traditional, story-like format. Records assessments, clinical decisions, and nursing interventions.

Answer 23

Narrative Notes

Question 24

Data: Subjective and objecTIVE information, Action: Interventions provided, Response: Patient’s reaction or outcome

Answer 24

DAR/Focus charting

Question 25

Often used in interdisciplinary settings. Subjective: What the patient says, Objective: What the nurse observes, Assessment: Clinical impression or diagnosis, and Plan: What to do next.

Answer 25

SOAP

Question 26

This note has a specific nursing focus. This consist of the Problem (Nursing diagnosis), Intervention (What was done) and Evaluation (Outcome of the intervention).

Answer 26

PIE Note

Question 27

POMR stands for...?

Answer 27

Problem-Oriented Medical Record

Question 28

A structure approach to medical documentation. Focuses on patient problems as the core of documentation. Design to improve organization, communication, and continuity of care.

Answer 28

POMR (Problem-Oriented Medical Records)

Question 29

Four Basic Components of POMR

Answer 29

Database Problem List Initial Plans Progress Notes

Question 30

Structured Documentation System

Answer 30

POMR (Problem-Oriented Medical Record)

Question 31

Structure progress note format within POMR

Answer 31

SOAP format