Week 3 - Class 2 (Health History & Documentation) Flashcards

Question

What is documentation?

Answer 1

It is a record and a timeline - Refers to what exact nursing care is provided to a PT (i.e. what was done and what was not done) - It keeps everyone current, including the client, and ensures continuity of care

Answer 2

Demonstrates that the nurse has applied the nursing knowledge, skill and judgment required by professional standards & regulations

Answer 3

All documentation, whether flow sheet or long-form note, is a legal record - It is in everyone’s best interest that documentation be complete, accurate, timely, and professional - Can be brought into court

Answer 4

“Supporting nurses’ development of information and knowledge management competencies, and designing continual quality improvement activities related to effective documentation.” - Why the reference to quality improvement activities? - This is in reference to one of nursing’s core values which is lifelong learning - There is always opportunity to become better at a nursing skill, even if (and for some, especially if: you’ve been doing it a certain way for a very long time “Developing performance management processes that provide opportunities to improve documentation.” - The best practice council does audits now and then of charts in the hospital setting to gather data about common practices amongst nurses and on particular units, and to gather data about gaps in practice and ways in which those gaps might be addressed through continued learning - You are never a finished product as a nurse “Providing adequate time to document appropriately and review prior documentation.” - Taking the time on your shift to documents appropriately and in keeping with standards of practice requires planning - You have to make time for it just like any other activity - It shouldn’t be left to the end, and it shouldn’t be rushed - It’s important that documentation actually does what it is supposed to do

Answer 5

BE: - Factual - Accurate - Concise - Relevant - Complete - Organized INCLUDE: - Proper grammar - Spelling - Punctuation - Professional language/terminology

Answer 6

- Do not erase or use white out (Why?) - Record pertinent facts - Do not leave blank spaces in the note (Why?) - Write legibly & in ink - Chart only for yourself (Except when?) - Avoid using generalized phrases - Begin each entry with date, time. - End each entry with signature & designation (WCTF-1 ) - Be considerate of language used (i.e. correct terminology)

Answer 7

Your errors need to be legible/trackable (if electronic) after your correct them - A single line to stroke through, write “err” with your initials, and continue writing - No scribbling, no squeezing words in above the line, legible

Answer 8

Yes! - It can change the meaning of the documentation Organize your thoughts! - Would another person get what you mean?

Answer 9

1) Avoid words such as “seems” or “appears” - This suggests an opinion rather than a fact 2) Avoid vague words such as “good” or “some” 3) Avoid giving an opinion, such as “the client is progressing well” - This is an interpretation and won’t mean the same thing to all caregivers * Be cautious of the word ‘normal' - It can be open to too much interpretation

Answer 10

“Subjective interpretation” is what is happening when the words “seems” or “appears” or “because” sneak into your writing - It’s just a matter of rephrasing to keep it bias-free and factual for the reader

Answer 11

1) Monitor q 2 hours and prn. 2) RTC immediately if increasing cough, dyspnea, fever, or if no resolution of symptoms in 3 days 3) Vital signs are within normal limits, patient is resting, reporting 2/10 on pain scale

Answer 12

SOAP S: Subjective O: Objective A: Analysis P: Plan

Answer 13

It should look like a paragraph and sound like point-form notes

Answer 14

1) Date and time - Military time 2) PT name 3) Physician 4) Title 5) Sections of SOAP - For clarity and standardization 6) Analysis is always phrased " (problem) related to (cause/possible cause). - Cause can be unknown (i.e. unknown origin or unknown etiology)

Answer 15

- Military clock | - Round to nearest '5

Answer 16

Proper: - Concise points - Problem related to cause - Signature correct Improper - Lengthy sentences, very wordy - Objective Data: Some irrelevant info, just make a quick comment and be specific (combine pieces of info) - Analysis is not worded properly (i.e. problem related to cause) - Plan: Weak, more specific, do more for the nurses working after you - Signature in wrong place

Answer 17

1) As in the previous slide, if I don’t fill up my last line, and I determine that there is room for my signature, I can sign on the right and fill in any space with a line. 2) If I haven’t quite filled up the line, but there isn’t enough room for me to apply my signature without it being all squished and illegible, then I can do this. 3) If I go all the way to the end of the line with my writing leaving no room for anything else, I drop down to the next line and sign.

Week 3 - Class 2 (Health History & Documentation) Flashcards

(41 cards)