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Flashcards in Unit 2 Deck (36)
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1

What does PIPEDA stand for?

Personal info protection & electronic documents act

2

Acuity Record

Based on type & # of nursing interventions required for providing 24 hrs care
Ex: 1-5 scale
1 = totally dependent for bathing
5 = can bathe independently

3

What are the purposes of chart/record

1. Communication
2. Legal document
3. auditing
4. Education
5. research, ect

4

2 Types of Records

1. Source-oriented
2. Problem-oriented

5

Explain source-oriented records

- each discipline has own section
- predictable pattern
- disciplines document in own section
- Most common in acute care

6

Explain Problem-oriented records

- based on pt's problem
- all disciplines document in same area
- medically-based source
- single diagnosis
- Multiple problems #'ed & prioritized

7

Explain narrative charting

longest
Writing story ~ pt
Date & Time (2 lines) *** a must
Short form & abbrev
Remarks = no white space

8

SOAP

Subjective
Objective
Assessment
Plan

9

SOAPIE(R)

Subjective
Objective
Assessment
Plan
Intervention
Evaluation
(Revision)

10

PIE

Problem
Intervention
Evaluation
(Problem focused)

11

Focus Charting: DAR(P)

Data
Action
Response
(Plan)

12

Characteristics of focus charting

Based on pt's concerns
Away from medical focus
Always in combination w/ other forms of documentation

13

About Charting By Exception (CBE)...

Very common
Looks @ normal for "average human"
Only document deviations
includes observations, nsg interventions, pt response

14

About Computerized systems

Has std care plans --> individualize for pt
efficient & effective (ex: upload x-rays)
Some legal implications

15

About Case Management

uses critical pathways = care maps
Can use CBE
pathway for specific disease
Common in ER
Document deviations
Difficult for complex patients

16

Types of forms

1. Admission database
2. Standardized care plan
3. Kardex
4. Flowsheets
5. Progress notes
6. Discharge summary
7. Longterm/ home care
8. Incidence reports

17

Characteristics of KARDEX

- not permanent
- important in ICU
- Can be in pencil

18

Discharge summary

simple terms
2 copies (1 for pt , 1 for chart)

19

Guidelines of Documentation

Timely
logical order
meet std's
legible (blue/black ink)
accepted abbrev/ symbols
sign ALL entries
facts only
accurate
thorough & complete

20

All documentation contains:

1. assessment data
2. nsg interventions
3. outcomes

21

Of the following types of documentation, which takes the longest, but gives the most detail?
A. Narrative
B. SOAP
C. Focus charting
D. Chart by exception

A. Narrative

22

Which of the following is the best example of quality documentation?
A. Enema administered as ordered, with patient in the left side-lying position
B. Patient seemed depressed today; not doing as well as before
C. Quarter-sized lump noted on left elbow; patient states pain is “better”
D. 6-cm incision on right lower quadrant, edges pink and well approximated with sutures; no drainage noted

D. 6-cm incision on right lower quadrant, edges pink and well approximated with sutures; no drainage noted

23

Which of the following is a guideline for legally sound documentation?
A. Record all entries legibly and in blue ink.
B. If an order is questioned, record that clarification was sought.
C. To use time more efficiently, wait until the end of shift to record what happened throughout the shift.
D. If an error is made, use correction fluid to maintain neatness. Then record the note correctly over dried correction fluid to make optimum use of space.

B. If an order is questioned, record that clarification was sought.

24

Which of the following is one purpose of the patient’s medical record?
A. Education and research
B. Ensuring accurate change-of-shift reports
C. Legal documentation and maintenance of incident reports
D. Auditing–monitoring and ease in locating procedure guidelines

A. Education and research

25

Which of the following represents a breach of confidentiality and privacy?
A. A patient is allowed to see and get copies of the patient’s medical record.
B. A nurse telephones the patient’s church to have the patient’s name placed on a prayer list.
C. A certified nursing assistant documents vital signs on a graphic sheet in the patient’s chart.
D. A student nurse covers the patient’s identifying information while copying the patient’s medication administration record and uses the copy to look up the medications in a drug book while on the unit.

B. A nurse telephones the patient’s church to have the patient’s name placed on a prayer list.

26

A patient is complaining of pain at 0400. The nurse telephones Dr. Rice and receives an order for oxycodone hydrochloride 5 mg one tablet every four hours as needed. It is wise for the nurse to do which one of the following?
A. Repeat the prescribed order back to the physician.
B. Document the following immediately on the physician’s order sheet: “0415 oxycodone hydrochloride 5 mg q4h prn. T.O. Dr. Rice.”
C. Complete an incident report to assist the unit’s quality improvement program so that awakening physicians during the night can be avoided.
D. Wait until the physician makes rounds in the morning and remind him to write the order to cover the nurse for the oxycodone hydrochloride the nurse gave during the night

A. Repeat the prescribed order back to the physician.

27

As the nurse enters the patient’s room, the nurse notices that he is anxious to say something. The patient quickly exclaims, “I don’t know what’s going on; I can’t get an explanation from my doctor about the results of my test. I want something done about this.” Which of the following is the most appropriate documentation of the patient’s emotional status?
A. The patient has a defiant attitude.
B. The patient appears to be upset with his physician.
C. The patient is demanding and complains frequently.
D. The patient stated that he felt frustrated by the lack of information he has received regarding his diagnostic tests.

D. The patient stated that he felt frustrated by the lack of information he has received regarding his diagnostic tests.

28

A manager is reviewing the nurses’ notes in a patient’s medical record. She finds the following entry: “Patient is difficult to care for, refuses suggestion for improving appetite.” Which of the following directions should the manager give to the staff nurse who entered the note?
A. Avoid rushing when charting an entry.
B. Use correction fluid to remove the entry.
C. Draw a single line through the statement and initial it.
D. Enter only objective and factual information about the patient.

D. Enter only objective and factual information about the patient.

29

A nursing instructor is helping a student nurse with discharge planning for a patient. The instructor realizes that further education is needed when the student nurse says which of the following?
A. “I need to go over the patient’s medications with him in terms he will understand.”
B. “I really can’t start discharge planning until the physician writes the discharge orders.”
C. “I will give the patient’s wife the appointment time I scheduled for follow-up and a list of agencies that provide medical supplies.”
D. “I will review signs and symptoms of infection with the patient so he will know what to watch for and will realize he should seek medical treatment if these occur.”

B. “I really can’t start discharge planning until the physician writes the discharge orders.”

30

Which of the following is a method of charting in which the nurse writes a progress note only when the standardized statement on the form is not met?
A. Narrative method
B. Source record
C. Problem-oriented medical record
D. Charting by exception

D. Charting by exception