Unit 9 - Documentation

Question 1

Documentation is defined as written evidence of:*
1.
2.
3.

Answer 1

Written evidence of:

• interaction between all people and organizations
• administration of test procedures, treatments and client education/ TAKING TEST/DATA
• the results of client response to diagnostic test and interventions/ EXPLAINING TEST/DATA AND INTERVENTIONS

Question 2

What is reporting?*

Answer 2

when two or more people share information about client care verbally, email, telephone, report
when two or more people share information about client care verbally, email, telephone, report

Question 3

Written Communication: What is the purpose of the client record?*

Answer 3

1. Communication – interdisciplinary
2. Assessment –History, client record
3. Care Planning - Nursing care plan
4. Quality Assurance -
   Institutional and The Joint Commission
   Insures standards of care are met
5. Reimbursement
6. Legal Document
7. Research – collect significant data of course of diseases and treatment responses
8. Education

Question 4

Principles of Data Entry & Management*

Answer 4

1. Accuracy*
2. Be complete*
3. Be concise
4. Be objective
5. Be organized
6. Be timely

Question 5

Principles of Data Entry & Management: Accuracy

Answer 5

1. Accuracy - unless otherwise noted it is assumed you witnessed data. So correct errors (do not erase) and be precise.

Question 6

Principles of Data Entry & Management: Be Complete

Means include what information?

Answer 6

New or changed information
Signs and symptoms 
Client behaviors
Nursing interventions
Medications given
Physician’s orders carried out
Client teaching and responses

Question 7

Principles of Data Entry & Management: Be Concise

Answer 7

Use phrases rather than complete sentences (he/she. Pt. client , nurse are assumed)

Use acceptable abbreviations
If unsure write it out
Watch caps and small letters in abbreviations

Avoid abbreviations with 2 meanings

Question 8

Principles of Data Entry & Management: Be Objective

Answer 8

Identify source or context of subjective information- do not interpret statements
Chart what you observed or what was said
Avoid derogatory terms

Question 9

Principles of Data Entry & Management: Be Organized

Answer 9

Be sequential or categorical –
Same information does not need to be charted multiple times
Don’t stop part way through note with plan to finish later

Question 10

Principles of Data Entry & Management: Be Timely

Answer 10

Record medications when given
Record changes in condition – may need record of changes in emergency
Indicate time of documentation – if information occurred before that time indicate time –
Military time
Prioritize Documentation

Question 11

High Risk Errors in Documentation

Answer 11

1. Falsifying client records
2. Failure to record changes in clients condition
3. Failure to document that physician was notified when clients condition changed
4. Inadequate admission assessment
5. Failure to document completely
6. Failure to follow agency standards or policies on documentation
7. Charting in advance

Question 12

Electronic Medical Records

1. What is it?
2. What does it limit?
3. What does it allow?
4. When is it available?
5. How many people is it available for at any given time?
6. When can information be documented?
7. What can be standardized?**
8. What can data be used for?

Answer 12

1. electronic format for client records, it is a database with variety of information
2. limits access information to specific healthcare personnel
3. allows accessibility beyond the primary institution (other facilities you visit can see it) because it is accessed by entire system (advocate)
4. available immediately
5. more than one
6. immediately documented at point of care
7. terminology and format for easy access to info needed
   8, billing, pharmacy, quality assurance, restocking units

Question 13

Computer Based Patient Record CPR

1. Where is it accessible
2. Who does it follow
3. What are the 3 benefits

Answer 13

1. accessible outside of primary institution
2. follows patient
3. Benefits:
4. Clients share health care information with any practitioner
5. Travel
6. Emergency

Question 14

What is Point of Care

Answer 14

Documentation at the bedside

Portable computers COWS WOWS

Question 15

Plan of Care *

1. What does it contain
2. May be ___ plans that are ___ to the ___.
3. Should be ___ at ____.
4. Recorded on ___ ___.

Answer 15

1. Contains nursing diagnoses, goals, outcome criteria, interventions and evaluations criteria
2. May be standardized plans that are individualized to the client
3. Should be initiated at admission
4. recorded on client record

Question 16

Kardex Patient Care Summary

1. May be __ ___ ___ out.
2. Describes:
3. The goal of it is to do what?
4. If hand written use __ __ for non-___ items & ___ for ___ items.
5. ___ warnings

Answer 16

1. computer generated print out
2. basic - up to date information needed for client care
3. To provide continuity of care
4. If hand written use black ink for non-changing items & pencil for changing items
5. Highlight warnings ALLERGIES

Question 17

Types of progress nursing note

Answer 17

narrative

Question 18

Narrative
1. ___ accoun of clients day
2. ___ and ___ care and ___ care included
3. may be used in combination with a __ ___.
Advantage:
Disadvantage:

Answer 18

1. Sequential account of client’s day
2. Assessment and nursing care and maintenance care included
3. May be used in combination with a flow sheet

Advantage: Time sequence maintained
Disadvantage: Lengthy, difficult to identify progress towards goals when evaluating client’s progress

Question 19

SOAP, what does it mean? Define each letter.

Answer 19

S Subjective
Direct quotes
information elicited from client that only he/she knows
May be none – left blank

O Objective
Health assessment, treatments completed, Lab Data, Anything measurable, visible, palpable, audible
Anything done to or for the client (e.g. MD notified of labs)

A Assessment / Analysis
Interpretation of the conclusions drawn about the subjective and objective data
Initial assessment states the problem After that the A should describe the client’s condition and level of progress rather than merely restating the problem

P Plan
The plan of care designed to resolve the stated problem
What will you and other nurse do
When , How

Question 20

SOAP

1. only relates to __ ___
2. who uses it?
3. Start with __ ___ must have a __ ___.***
4. Not associated with _ _ _ _ _.

Answer 20

1. one problem
2. all healthcare members
3. starts with problem statement, must have a problem list.
4. not associated with NANDA

Question 21

SOAP

1. Advantages:
2. Disadvantages:
3. Alternative:

Answer 21

1. Advantages :
Interdisciplinary 
easy to track progress of one problem
2. Disadvantages 
Difficult to master 
Can not chart general information since Problem focused
3. SOPIER

Question 22

PIE define & explain**

Answer 22

P Problem - Nursing Diagnosis usually referred to by number #

I Interventions : Completed to deal with the problem

E Evaluation : effectiveness of the interventions

Question 23

PIE:**

1. _____ must be ___ into this charting - since ___ is not included in format.
2. Advantages
3. Disadvantages:
4. Allows what data to be added to charting?

Answer 23

1. Flowsheet/incorporated/assesment
2. Advantages: Problem centered, shorter than SOAP format
3. Disadvantage:
   Assessment not related to problems
   Not multidisciplinary
4. Assessment data

Question 24

Focus Charting/DAR

1. Define & explain DAR
2. list advantages
3. list disadvantages

Answer 24

1. intended to make the client and client concerns the focus of care
   D Data
   Combines objective, subjective, health assessment, lab data etc

A Action
Planning and Interventions includes immediate and future plans

R Response
Effects of your interventions on client, state if not enough time to evaluate, new problems

2. Advantages: Focus selected on priority basis, easy to understand
   Holistic view of client and needs
   Easy to use since all three components do not need to be recorded
   each time
3. Disadvantages: Problems may be lost since active problems not always focus of note Change of plans not reflected, Time sequence may be lost, Action part may be redundant to NCP or flow sheets – Not Multidisciplinary

Question 25

Flow Sheets 1. What does it allow for 2. Advantages** 3. Disadvantages**

Answer 25

1. Allows immediate documentation of routine care if WNL info included: Assessments, Treatments, Graphic Vital Signs Intake and Output IV’s 2. Advantages: Thorough , space efficient , readily available, encourages immediate documentation 3. Disadvantages: categories missing or inappropriate, lines small, limited specificity

Question 26

Types of flow sheets

Answer 26

Graphic record 24-hour fluid balance record Medication record 24-hour patient care records and acuity charting forms

Question 27

Charting by Exception (CBE)** 1. When is it required? 2. Disadvantage: ___ must have clearly __ ___ of care and everyone must ___ upon them.

Answer 27

1. Charting required only for incidents that fall outside the parameters set by standards of care or normal assessment findings 2. Disadvantage: Agency must have clearly state standards of care and everyone must agree upon them

Question 28

Critical Pathways** 1. Used for 2. Based on 3. Used by 4. Additional charting used only if... 5. Who initiates the pathway? 6. When does the nurse sign?

Answer 28

1. Used for clients with predictable conditions 2. Based on Best practice criteria 3. Utilized by multidisciplinary team 4. Additional charting used only if exception to pathway occurs 5. MD initiates pathway 6. Nurse signs when intervention when standard pathway interventions are completed on the date indicated

Question 29

Discharge | What does documentation include?

Answer 29

Documentation includes discharge orders and teaching completed Includes diagnoses at discharge, medications and prescriptions if needed , treatments needed at home with instructions and supplies needed and given to client , diet, special care instructions – shower , next clinic appt , emergency numbers and names , activity orders esp return to work or school

Question 30

Discharge 1. Why does the patient sign discharge summary? 2. What does the client receive?

Answer 30

1. Patient signs discharge summary to acknowledge that information was given to him at discharge 2. Client receives a copy of the discharge summary

Question 31

Incident Report 1. What is it used for? 2. What does it evaluate? 3. What does it described? 4. How is and isn't it documented?

Answer 31

1. Risk managment and is a Confidential document used for internal review by legal, insurance, and quality assurance committees 2. Evaluates the effectiveness of hospital policies and procedures 3. Describes : How the incident occurred Impact on the client Outcome of the incident 4. Incident is objectively documented according to hospital policy. Is not placed in client medical records.

Question 32

5 methods of Reporting

Answer 32

``` Face-to-face meetings – bedside reporting Telephone conversations Written messages Audio-taped messages Computer messages ```

Question 33

Verbal Handoff | Change of shift bedside reporting reports include

Answer 33

1. Name, age, room number of client 2. Medical diagnoses, major procedures or surgery (date) 3. Name of physician/group 4. Significant nursing diagnoses and progress toward goals 5. Significant assessment data 6. New diagnostic or laboratory test results 7. Specific treatments 8. IV type, rate, and amount remaining

Question 34

What are ways to confer about care? 3

Answer 34

1. Consultations and referrals - provides assessment and treatment plan for other MD or healthcare workers 2. Nursing and interdisciplinary team care conferences 3. Nursing care rounds - discuss the plan of care - nurse is responsible for advocating for clients needs and providing nursing assessment and plan

Question 35

When reporting to primary care provider via telephone the nurse should: 1. ___ nursing assesment 2. Have... 3. Provide 4. Document..

Answer 35

1. Focused nursing assessment 2. Have client’s record on hand for reference 3. Provide status report Signs & Symptoms, changes in assessment VS, Lab data – treatments and response 4. Document conversation in client record

Question 36

Template for Communication: SBAR 1. what does SBAR mean?** 2. When is it used?

Answer 36

1. SBAR : S - Situation: statement about problem/ whats going on B - Background: what is the clinical background information that is pertinent to the situation A - Assessment - what did you find? analysis and considerations of options R - Recommendations: what action/recommendation is needed to correct that problem? what do you want to happen for this patient? 2. Used in all communication hand offs; shift change, ER reports, transfers Charge nurse to charge nurse, Nurse to MD