OTHER SOURCES OF CLIENT DATA

Question 1

OTHER SOURCES OF DATA

Answer 1

1. PRIMARY SOURCE OF DATA
2. SECONDARY SOURCES OF DATA

Question 2

• medical information held about an individual patient.
• include information relating to their past and current health or illness, their treatment history, lifestyle choices
  and genetic data.

Answer 2

CLIENT’S DATA

Question 3

the PATIENT is the primary source of data collection in health assessment

Answer 3

PRIMARY SOURCE OF DATA

Question 4

data include information from the patient’s chart, family members, or other health care team members

Answer 4

SECONDARY SOURCES OF DATA

Question 5

*Several terms are used interchangeably to describe a patient’s medical chart, including medical records, health
records, and patient/client charts.
* is a complete and total record of a patient’s clinical data and medical history
* All refer to a private medical record that contains systematic documentation of an individual patient’s
important clinical data and medical history over time.
* Typically, patient charts include vitals, medications, treatment plans, allergies, immunizations, test results,
patient demographics, diagnoses, progress notes, and reports.
* All information in patient charts comes from nurses, lab technicians, physicians, and other practitioners
involved in the patient’s care
* Patient medical charts display a patient’s key medical information so practitioners can make more accurate
diagnoses and develop treatment plans with better outcomes.

Answer 5

CLIENT’S CHART

Question 6

“Requires client record to be timely, complete, accurate, confidential and specific to the client.”

Answer 6

According to JCAHO
* The Joint Commission (formerly known as Joint Commission on Accreditation of Healthcare Organization) is
the peer review organization which provides the primary review of hospitals and healthcare providers.

Question 7

“ . . . the nurse has a duty to maintain confidentiality of all patient information.”

Answer 7

According to ANA Code of Ethics
* The American Nurses Association Code of Ethics was developed as a guide for carrying out nursing
responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession.

Question 8

“Accurate documentation of actions and outcomes of delivered care is the hallmark of nursing
accountability.”

Answer 8

3. According to Code of Ethics for Filipino Nurses
   * The Code of Ethics for Filipino Nurses outlines ethical principles and guidelines for registered nurses in their
   interactions with people, practice, co-workers, society, environment, and the nursing profession.

Question 9

requires the creation of
national standards to protect sensitive patient health information from being disclosed.

Answer 9

4. According to HIPAA
   * The Health Insurance Portability and Accountability Act of 1996 is a federal law that

Question 10

5. Ensuring confidentiality of computer records:

Answer 10

*Personal password that is not to be shared
* Never leave a computer terminal unattended after logging on
* Do not leave client information displayed on the monitor where others may see it
* Shred all unneeded computer-generated worksheets
* Know facility’s policy and procedure for correcting an entry error
* Follow agency procedures for documenting sensitive material
* IT personnel must install a firewall to protect server from unauthorized access

Question 11

6. In general . . . .

Answer 11

• Confidentiality and privacy of all patient information is needed.
• Client’s record protected legally as a private record of client’s care
• Responsibility in using records for the purpose of education and research

Question 12

The primary purpose of the ______________ is to provide continuity of care which means documenting services, so others
have a source upon which to base care

Answer 12

patient record

Question 13

PURPOSES OF CLLIENT RECORDS

Answer 13

1. Communication
2. Planning Client Care
3. Auditing Health Agencies
4. Research
5. Education
6. Legal Document
7. Health Care Analysis

Question 14

Prevents fragmentation, repetition and delays in client care as it is used by health care professionals
in communicated with each other and with the client.

Answer 14

Communication

Question 15

Client records are kept for several purposes, including communication, planning client care,
auditing health agencies, research, education, reimbursement, legal documentation, and health care analysis.

Answer 15

Planning Client Care

Question 16

Review client records for quality assurance to determine if the hospital is meeting its
stated standards

Answer 16

Auditing Health Agencies

Question 17

Data in the record can be used for nursing research. Treatment plans for several clients with the same health
problems can yield information helpful in treating other clients.

Answer 17

Research

Question 18

Client records may use data as educational tools

Answer 18

Education

Question 19

Client’s records serve as evidence in court. Admissible in court as evidence unless client objects
because information client gives to primary care provider is confidential

Answer 19

Legal Document

Question 20

Records may help health care planners identify agency needs, such as overuse or underuse of
hospital services.

Answer 20

Health Care Analysis

Question 21

KEY ELEMENTS OF A CLIENT’S MEDICAL CHART

Answer 21

1. Patient Demographics
2. Financial Information
3. Consent and Authorization Forms
4. Medical History (Treatment)
5. Nursing Records
6. Diagnostic Procedures and Laboratory Results
7. Operative and Anesthesiology Report
8. Discharge Summary

Question 22

• Filled out by the patient on their first visit to the doctor’s office and updated as needed.
• It contains information that is directly related to the patient, such as their last name, first name, gender, DOB,
  marital status, address, telephone number, employment status, employer’s address and phone number, and
  name and contact information for the person who is responsible for them.

Answer 22

1. Patient Demographics

Question 22

• Assignment of benefits: the patient or guarantor authorizes their health insurance company to make payments
  directly to the physician, medical practice, or hospital for the treatment received.
• Insurance information includes Insurance payer’s name, address, and phone number, Subscriber name, Policy
  number, Responsible party name, address, and phone number, Responsible party employer, occupation, and
  employer phone number Patient’s relationship with the insured.

Answer 22

2. Financial Information

Question 23

• This document outlines any medical ailments the patient has had in the past and present.
• A complete head-to-toe evaluation of the patient’s physical state is included in the physical examination (PE).
• Medical History includes: Chief Complaint, History of illness (present and past), vital signs, physical
  examination, surgical history (for patients who had surgery), obstetric history (for pregnant women), allergies,
  family history, immunization history (for pediatric clients), habits such as exercise, diet, sm

Answer 23

4. Medical History (Treatment)

Question 24

• It is a signed statement from the patient or guardian approving the course of treatment.
• For any course of treatment that is above routine medical procedures, the physician must disclose as much
  information as possible so the patient may make an informed decision about his/her care.
• Needs Consent/Authorization Forms: Diagnosis and chances of recovery. The recommended course of
  treatment.
• Things to be discussed before signing the forms: Risks and benefits involved in the treatment, Risks if no
  treatment is taken, Probability of success if treatment is taken Recovery challenges and length of time.
• Release of Information
  Need to bring:
  o A valid authorization to release protected health information. Identity verification such as a driver’s
  license. A description of the information to be used or disclosed.
  o The name of the person or organization authorized to disclose the information.
  o The name of the person or organization authorized to disclose the information, and the information
  is to disclose.
  o An example of this are the birth certificates to be claimed and death certificated as well.

Answer 24

3. Consent and Authorization Forms

Question 25

o Physician’s orders for the patient to receive testing, procedures, or surgery including directions to other
treatment team members.
o Prescriptions for medications and medical supplies or equipment for the patient’s home use.
o Findings opinions from consulting physicians.

Answer 25

• Doctors Order Sheet

Question 26

*In these records, vital indicators including blood pressure, temperature, pulse, respiration, intake, output, etc of
the patient are recorded.
* Nurse’s notes include documentation separate from the physician including Assessment, Nursing Diagnosis,
Planning, Intervention, & Evaluation.

Answer 26

5. Nursing Records

Question 27

Prescribed medication including dose, method of intake, and schedule

Answer 27

• Medication List

Question 28

include new information and changes during patient treatment.

Answer 28

• Progress Notes

Question 29

• Surgeon’s written account of the process, including the preoperative and postoperative diagnoses, the precise
  specifics of the surgical procedure, the patient’s response to it, and any complications that may have arisen.
• Information from the attending anesthesiologist or anesthetist that provides a thorough account of anesthesia
  during surgery, including the drugs used, their dosage and administration time, the patient’s reaction, the
  monitoring of vital signs, how well the patient tolerated the anesthesia, and any complications that may have
  arisen

Answer 29

7. Operative and Anesthesiology Report

Question 30

• These comprise documents containing the findings of every diagnostic test and laboratory procedure that the
  patient underwent.
• The findings or outcomes of samples taken from the patient, such as bone marrow, blood, or tissue, are
  documented in the pathology report. Record of findings from radiology testing, Ultrasound, ECG.

Answer 30

6. Diagnostic Procedures and Laboratory Results

Question 31

• A summary of the patient’s hospital care, including the date of admission, the diagnosis, the course of treatment
  and any responses from the patient, the outcomes of the tests, the final diagnosis, the follow-up plans, and the
  date of discharge.

Answer 31

8. Discharge Summary

Question 32

HOW TO KEEP GOOD NURSING RECORD

Answer 32

• Part of the nursing care we give to our patients.
• Without clear and accurate nursing records for each patient, endorsement to the next shift of nurses will be incomplete.
• The quality of record-keeping can be a good (or bad) reflection of the standard of care given to patients.
• Careful, neat, and accurate patient records are the hallmarks of a caring and responsible nurse, but poorly written records
  can lead to doubts about the quality of a nurse’s work.
• Nursing records are proof that you have fulfilled your duty of care to the patient,
• Poor record-keeping can mean negligence. even if provided the correct care - and this may cause you to lose your right
  to practice.

Question 33

• Ensure that records are accurate and complete to effectively manage the client and allow for good
  communication between the nurse and other healthcare members.
• Keeping

Answer 33

NURSE’S RESPONSIBILITY

Question 34

COMMON RECORD KEEPING FORMS (Common forms used in the hospital)

Answer 34

1. Admission Nursing Forms
2. Flow Sheets and Graphic Records
3. Kardex
4. Nurses Progress Notes
5. Discharge Summary Forms

Question 35

• A nurse completes a nursing history form when a patient is admitted to a nursing unit.
• The form guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems.

Answer 35

1. Admission Nursing Forms

Question 36

• Flow sheets allow you to quickly and easily enter assessment data about a patient
• It helps team members quickly see patient trends over time and decrease time spent on writing narrative
  notes.

Answer 36

Flow Sheets and Graphic Records

Question 37

Body temperature, pulse, respiratory rate, blood pressure, weight, other significant clinical data

Answer 37

Graphic record

Question 38

All routes measured and recorded.

Answer 38

Intake and output

Question 39

• Date of order, expiration date, name and dose, frequency and route of
  administration, nurse’s signature

Answer 39

Medication administration record

Question 40

• Concise method of organizing and recording data
• Series of cards kept in a portable index file or on computer-generated form.
• Information quickly accessible
• Pertinent information about the client arranged in sections.

Answer 40

3. Kardex

Question 41

• Made by nurses.
• Provide information about the progress a client is making toward achieving desired outcomes.
• Include information about client problems and nursing interventions.

Answer 41

4. Nurses Progress Notes

Question 42

• Completed when client discharged - terms that can be readily understood.
• Completed when client transferred to another institution.
• Include some or all the following: Description of client’s physical, mental, and emotional status, resolved health problems, Treatments to be continued, Current medications, include restrictions that relate to activity, diet, and bathing, Functional/self-care abilities, Comfort level, Support networks, Client education, Discharge
  destination, Referral services.

Answer 42

5. Discharge Summary Forms