Basic Nursing Week 3 – Flashcards

Assessments Medication administration Treatments and responses Client education

communication, legal documentation, financial billing, education, research, and auditing.

Subjective and objective data - Nurses should document subjective data as direct quotes, within quotation marks, or summarize and identify the information as the client's statement.

descriptive and should include what the nurse sees, hears, feels, and smells. Document without derogatory words, judgments, or opinions. Document the client's behavior accurately. Instead of writing "client is agitated," write "client pacing back and forth in his room, yelling loudly."

Document facts and information precisely - what the nurse sees, hears, feels, smells - without any interpretations of the situation. Only those abbreviations and symbols The Joint Commission and the facility approve are acceptable.

Document information that is comprehensive and timely. Never pre-chart an assessment, intervention, or evaluation.

Communicate information in a logical sequence.

Begin each entry with the date and time. Record entries legibly, in non-erasable black ink, and do not leave blank spaces in the nurses' notes. Do not use correction fluid, erase, scratch out, or blacken out errors in the medical record. Make corrections promptly, following the facility's procedure for error correction. Sign all documentation as the facility requires, generally with name and title. Documentation should reflect assessments, interventions, and evaluations, not personal opinions or criticism of others' care.

show trends in vital signs, blood glucose levels, pain level, and other frequent assessments.

records information as a sequence of events in a story like manner Can use with source- or problem-oriented system "Story" of care in chronological format Tracks the client's changing status Can be lengthy and disorganized

uses standardized forms that identify norms and allows selective documentation of deviations from those norms. Chart only significant findings or exceptions to norms Streamlines charting and saves time Uses preprinted forms and checklists Inadvertent omissions are biggest problem

S - Subjective data O - Objective data A - Assessment (includes a nursing diagnosis based on the assessment) P - Plan

P - Problem I - Intervention E - Evaluation Used only in problem-oriented charting Establishes an ongoing plan of care

D - Data A - Action R - Response

Nurses give this report at the conclusion of each shift to the nurse assuming responsibility for the clients. Formats include face to face, audio taping, or presentation during walking rounds in each client's room (unless the client has a roommate or visitors are present).

Include significant objective information about the client's health problems. Proceed in a logical sequence. Include no gossip or personal opinion. Relate recent changes in medications, treatments, procedures, and the discharge plan.

Have all the data ready prior to contacting any member of the inter professional team. Use a professional demeanor. Use exact, relevant, and accurate information. Document the name of the person, the time, content of the message, and the instructions or information received during the report.

It is best to avoid these, but they are sometimes necessary during emergencies and at unusual times. Have a second nurse listen to a telephone prescription. Repeat it back, making sure to include the medication's name (spell if necessary), dosage, time, and route. Question any prescription that may seem inappropriate for the client. Make sure the provider signs the prescription in person within the time frame the facility specifies, typically 24 hr.

These should include demographic information, medical diagnosis, providers, an overview of health status (physical, psychosocial), plan of care, recent progress, any alterations that might become an urgent or emergent situation, directives for any assessments or client care essential within the next few hours, most recent vital signs, medications and last doses, allergies, diet, activity, special equipment or adaptive devices (oxygen, suction, wheelchair), advance directives and resuscitation status, and family involvement in care and health care proxy.

Incident/variance reports are an important part of a facility's quality improvement plan. An incident is the occurrence of an accident or an unusual event. Examples of incidents are medication errors, falls, and needlesticks. Nurses must document the facts without judgment or opinion. Nurses must not refer to an incident report in the client's medical record. Incident reports contribute to changes that help improve health care quality.

C. A bone scan that is scheduled for today

B. The client states he fell in the shower and was able to get himself back into his chair.

B. Put the date and time on all entries. C. Document objective data, leaving out opinions.

A. The physical therapist did not ambulate the client today. B. The skin barrier's seal stays on in bed but loosens when the client stands. D. The wound care nurse will see the client later today.

A. Repeat the details of the prescription back to the provider. B. Have another nurse listen to the telephone prescription. C. Obtain the prescriber's signature on the prescription within 24 hr.

Managing and processing information necessary to make decisions

Managing and processing information applying to nursing practice, education, and research

unprocessed numbers, symbols, words; no context

groupings of processed data

meaningful information created by grouping and compiling information

appropriate use of knowledge

B, false There are many risks of violating HIPAA regulations when "faxing" client medical records. The risks of inadvertent disclosure of client information include: ● Pages of information being left in/on the "sending" FAX machine, desks, or workstations ● The "receiving" FAX machine being in an unsecured/ unmonitored area ● The "receiving" FAX machine accepting FAXs when offices are closed (making info available to employees of cleaning agencies) ● Misdialing/sending information to the wrong receiver

B. Complete the log off for the physical therapist before beginning her documentation To ensure that documentation is attributed to the correct user, it is important for each user to be logged onto a client electronic medical record under his or her own log-in code. In most institutions, logging-off does not require a code

Reduces barriers to evidence-based practice Facilitates a literature search Provides on-line sources for and of nursing research Provides literature databases

The act of recording client assessments and care in written or electronic form Creating a record of client assessments and care

Communication between providers Educational tool Legal documentation of care Quality improvement Research Reimbursement Education

Disciplines charted separately Variety of sections (e.g., admission, H&P, diagnostic, graphic, nurses' notes, progress notes, lab, rehab, DC plan, etc.) Data scattered; may lead to fragmentation

Organized around client problems Four components: database, problem list, plan of care, and progress notes Allows greater collaboration

Narrative PIE SOAPIER Focus Charting by Exception (CBE) FACT system

Subjective data Objective data Assessment Plan Intervention Evaluation Revision

Highlights the client's concerns, problems, or strengths in three columns Column 1: Time and date Column 2: Focus or problem being addressed Column 3: Charting in a DAR format: Data, Action, Response

Flow sheets individualize specific services Assessment with baseline data Concise progress notes Timely entries

Record of baseline data from which to monitor change Helps forecast future needs

● Chief complaint or reason for admission ● Physical assessment data ● Vital signs ● Allergy information ● Current medications ● ADL status and discharge planning information/ needs ● Data about client support system and contact information

● Record routine aspects of care (hygiene, turning) ● Document assessments; usually organized according to body systems ● Track client response to care (wound care, pain, intravenous fluids) ● Graphic records: used to record vital signs ● Intake and output record

● Comprehensive list of all ordered medications ● Provides information on client's medication allergies ● Documents scheduled/routine, PRN, STAT, or omitted doses ● Additional explanation may be required for nonroutine or omitted medications.

● Demographic data ● Medical diagnoses ● Allergies ● Diet/activity orders ● Safety precautions ● Intravenous therapy orders ● Ordered treatments (wound care, physical therapy), surgery, laboratory, and tests ● A summary of medications ordered ● Special instructions such as preferred intensity of care or isolation orders

● A combined charting and care plan form ● Maps out on a daily basis, from admission to discharge ● Client outcomes, interventions, and treatments for a specific diagnosis or condition ● Laboratory work, diagnostic testing, medications, and therapies included in the pathway

D. The progress notes and the MAR The nurse would document the administration of the medication itself on the MAR. He would also document the intervention and the client's response to the intervention in the progress notes.

● Informing other caregivers about the client's condition ● Nurse to nurse; nurse to physician ● Passage of vital information related to the client's status/plan of care

● Formal record of unusual occurrence or accident ● Not a part of patient's health record ● Quality improvement

May be ● Verbal ● Through walking rounds ● Audio-recorded report (not the preferred method)● Client demographics and diagnoses ● Relevant medical history ● Significant assessment findings ● Treatments (e.g., wound care, breathing treatments) ● Upcoming diagnostics or procedures ● Restrictions (e.g., diet, activity, isolation) ● Plan of care for the client ● Concerns ● Use a standardized format such as SBAR or situation background, assessment recommendation PACE or patient/problem assessment actions continuing changes evaluation

Your contact information Client demographics, diagnoses, reason for transfer Familycontactinformation Summaryofcare Currentstatus,includingmedications,treatments,and tubes in the client Presenceofwoundsoropenareasoftheskin Specialdirectives,codestatus,preferredintensityof care, or isolation required Alwaysaskifthereceiverhasanyquestions

Time of departure and method of transportation ● Name and relationship of person(s) accompanying client at discharge ● Condition of client at discharge ● Teaching conducted and handouts/informational matter provided to client ● Discharge instructions (including medications, treatments, or activity) ● Follow-up appointments or referrals given

Spoken to you; often during a client emergency ● Should be made for critical change in patient condition

Received by phone and transcribed onto chart order sheet ● Have an increased risk for errors Write the order only if you heard it yourself ● Make sure the verbal orders make sense with the client's status ● Repeat the order to confirm accuracy ● Spell unfamiliar names; pronounce digits of numbers separately Directly transcribe the order on the chart ● Date/time ● Text ● To followed by provider's name ● Your signature ● Physician or other prescriber must countersign within 24 hours

Be familiar with facility forms ● Chart in the required format ● Include all aspects of care ● Be accurate, complete, and consistent

Home-bound status ● Assessment highlighting changes in the client's condition ● Interventions performed (wound care, teaching, etc.) ● Client's response to interventions ● Any interaction or teaching that you conducted with caregivers ● Any interaction with the client's physician

Minimum data set (MDS) for resident assessment and care screening must be completed within 14 days of admission and updated every 3 months. 35 pages long

A summary of the client's condition ● An evaluation of the client's ability to perform ADLs ● The client's level of orientation and mood ● Hydration and nutrition status ● Response to medications ● Any treatments provided ● Safety measures used (e.g., bed rails)

Use a Head to Toe approach to assessment

Be accurate and nonjudgmental ● Adhere to the requirements for reimbursement ● Provide details about the client's condition, nursing interventions provided, and client response ● Document legibly and as soon as possible Record significant events or changes in condition ● Record any attempts you have made to contact the primary care provider ● Chart teaching performed ● Chart use of restraints, including reason for use, type of restraints, and frequent checks of the client Do not chart that you have filled out an occurrence report ● Chart any client refusal of treatment or medication ● Document any spiritual concerns expressed by the client and your interventions Always use black or blue ink for handwritten notes ● Date, time, and sign all notes ● Avoid subjective terms ● Use proper spelling and grammar ● Use only authorized abbreviations ● Document complete data about medications f a client refuses medication ● Recordonthemedicationadministrationrecordinnarrative form; chart the reason given ● Donotleaveblanklines ● Ifyoumakeamistake: For an entry that is one line: Draw a single line through the entry and write "mistaken entry" and your signature and designation For an entry the is 2 or more lines, cross out entry and write "mistaken entry" and your signature and designation. Don't try to hide a mistake Sign all your charting entries Full 1st and second name and designation