L2: Documentation

Question 1

A fundamental component of nursing activities such as assessment and care planning, accdg. to the various models which have been designed for these functions.

Answer 1

DOCUMENTATION

Question 2

• Continuity of care
• Furnishes legal evidence of the process of care.
• Promotes and facilitates the evaluation of the quality of patient care delivery.

Answer 2

IMPORTANCE OF PROPER DOCUMENTATION

Question 3

• Communication
• Planning client care
• Auditing health agencies
• Research
• Education
• Reimbursement
• Legal documentation
• Health Care Analysis

Answer 3

PURPOSES OF DOCUMENTATION

Question 4

• Takes place when two or more people share information about client care, either face to face of by telephone.
• Based on nursing process.

Answer 4

REPORTING

Question 5

Only ____ may receive telephone orders.
The order needs to be verified by reporting it clearly and precisely.

Answer 5

RNs

Question 6

The order should be countersigned by the ________ which made the order within the prescribed period of time.

Answer 6

PHYSICIAN

Question 7

Prescribed period of time

Answer 7

24 HOURS

Question 8

• When the call was made
• Who made the call/report
• Who was called
• To whom information was given
• What information was GIVEN
• What information was RECEIVED

Answer 8

THE NURSE MUST DOCUMENT THE FF:

Question 9

Improves communication and lessens the chance of misunderstanding between members of the health team.

Answer 9

USE OF COMMON VOCABULARY

Question 10

• Print if necessary.
• Do not erase or obliterate writing.
• State the reason for the error.
• Sign and date the correction.

Answer 10

LEGIBILITY

Question 11

• Always refer to the facility’s approved listing.
• Avoid abbreviations that can be misunderstood.

Answer 11

ABBREVIATIONS & SYMBOLS

Question 12

• Start every entry with the date and time.
• Chart in chronological order.
• Chart medications immediately after administration.
• Sign your name after each entry.

Answer 12

ORGANIZATION

Question 13

• Use descriptive terms to chart exactly what was observed or done.
• Use correct spelling and grammar.
• Write complete sentences.

Answer 13

ACCURACY

Question 14

Document in the nurse’s progress notes:
- Name and dosage of medication
- Name of the practitioner who was notified of the error.
- Time of the notification
- Nursing interventions or medical treatment.
- Client’s response to treatment.

Answer 14

DOCUMENTING A MEDICATION ERROR

Question 15

The nurse is responsible for protecting the privacy and confidentiality of client interactions, assessments, and care of client.

Answer 15

CONFIDENTIALITY

Question 16

• A factual record contains descriptive, objective information about what a nurse sees, hears, feels, and smells.
• An objective description is the result of direct OBSERVATION and MEASUREMENT.

Answer 16

FACTUAL

Question 17

The information within a recorded entry or a record must be complete, containing appropriate and essential information.

Answer 17

COMPLETE

Question 18

• Timely entries are essential in patient’s ongoing care. Delay in documentation leads to unsafe patient care.
• Health organizations use military time to avoid misinterpretation of AM and PM.

Answer 18

CURRENT

Question 19

• Communicate information in a LOGICAL order.
• It is effective when notes are concise, clear, and direct to the point.

Answer 19

ORGANIZED

Question 20

A shift and during change-of-shift reports. It is also used as a reference throughout the client data. (e.g., name, age, admission date, allergy)

Answer 20

KARDEX

Question 21

The information in this can be formatted to meet the specific needs of the client (e.g., graphic sheets for vital signs, intake & output record, skin assessment record).

Answer 21

FLOW SHEETS

Question 22

Used to document the client’s condition, problems and complaints, interventions, responses, achievement of outcome.

Answer 22

NURSES’ PROGRESS NOTES

Question 23

• Client’s status at admission and discharge
• Brief summary of client’s care
• Interventions and education outcomes.
• Resolved problems and continuing needs.
• Referrals
• Client instructions

Answer 23

DISCHARGE SUMMARY

Question 24

In relation to privacy, is the acceptance of responsibility for personal information protection.

Answer 24

ACCOUNTABILITY

Question 25

Each personal information controller is responsible for personal information under its control or custody, including information that have been transferred to a third party for processing, whether domestically or internationally, subject to cross-border arrangement and cooperation.

Answer 25

RA 10173 - DATA PRIVACY ACT OF 2012

Question 26

Originates from “privatus” and “privo” in latin and means “deprive of”.

Answer 26

THE CONCEPT OF PRIVACY

Question 27

Involves the confidentiality of information related to the patient and bodily privacy of the patient.
“Disclosure of patients case patients name to diseases, only patient to doctor”

Answer 27

PATIENT’S RIGHT TO PRIVACY