question

Explain the purpose of Documentation.

answer

It is an act of making it a written record. Records patient status and care.

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Reporting

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oral communication about the patients status

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Medical record or chart

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collection of documentation, orders, and other care information for a patient Present emphasis on health, now commonly referred to as Health record

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What is permanently kept in Health record?

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Care, in chronological order, provided by all healthcare providers. Patients responses to interventions and treatments Important facts about the client's health history, including past and present illnesses, examinations, tests, treatments, and outcomes

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How do Healthcare providers use documentation?

answer

Communication- use health record to communicate about patients status and care. Legal record- legal evidence of care provided to patient Continuity of care- can initiate orders for other nurses to carry out. Quality Improvement- healthcare organizations perform manual chart audits of written documentation. Results are used to identify ways to improve care, decrease length of stay, control costs, etc. Reimbursement-documentation needed to be reimbursed by 3rd party payers and to determine if treatments and interventions were needed.

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Why are standardized nursing languages important?

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Standardized nursing terminology helps measure nursing contribution to care and demonstrate the value of nursing by making nursing care and its effect on patient outcomes more visible in patient records. Allows researchers to retrieve nursing data for aggregation and analysis. With the use of nursing language in nursing documentation, evidence-based nursing care delivery has now been established. Standardized languages are important in EHR systems because computers require standardized information that can be converted into numerical code.

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Health records system

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The overall process by which all patient records are created, stored, and retrieved in an organization. Each healthcare agency determines the health record system that is used. Nursing leaders in each organization usually determines the documentation forms that nurses will use within the records system.

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Source-Oriented system

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members of each discipline record their findings in separately labeled section of the chart.

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A typical source-oriented record includes the following:

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Admission data Advance directives History and physical Physician's orders Progress notes Diagnostic studies Laboratory data Nursing notes Graphic data-numerical data recorded over time and displayed visually to see trends. Rehabilitation and therapy notes Discharge planning

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Source- Oriented system advantages

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Can easily find the care provided by each discipline

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Source-Oriented system Disadvantages

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May be fragmented and scattered throughout clients record. Difficult to find treatment and outcomes associated with particular problem. Need to look in multiple sections.

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Problem-Oriented Record Systems and its parts

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Organized around patient's problems. Consist of four parts: Data, problem list, plan of care, and progress notes.

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Problem-Oriented Record Systems Advantages

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There is a common problem list that includes input from all disciplines. It is easy to monitor the patients progress because each problem is readily identified in notes. Each discipline has ready access to the findings of other members in healthcare team, which can lead to greater collaboration.

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Problem-Oriented Record Systems Disadvantages

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POR system requires a cooperation between health care providers and diligence in maintaining a current database and problem list.

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Charting by exception (CBE)

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A system of charting in which only significant findings or exceptions to standards and norms of care are charted. To use effectively, you must know and adhere to professional, legal, and organizational guidelines for nursing assessments and interventions. CBE uses preprinted flow sheets to document most aspects of care. CBE assumes that unless separate entry is made, all standards have been met and patient has responded normally.

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CBE Advantages

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CBE reduces the amount of time spent on documentation, reduces repetitive charting of routine care, provides a record that is easily read and understood, and clearly highlights any variations from the expected plan of care.

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CBE Disadvantages

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Inadvertent omissions are the main problem. Critics say CBE requires nurses to be overly familiar with the organizations documentation standards and policies Makes it difficult to capture the skilled judgement of nurses Reduces care to such rote repetitions that you may forget to chart an exception to the established standards. Documentation can be time-sensitive and under CBE false documentation can be created by assuming that care has been done when it has not.

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Electronic Health Record (EHR) Systems

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consists of records that are entered via computer. Typically combine source-oriented and problem-oriented record styles, although Source-oriented is most common.

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Advantages of Electronic Records System

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Enhanced communication and collaboration among healthcare providers Improved access to information: people can access info at same time. Authorized persons can access information remotely, and integrate client information between multiple departments so that one area can immediately see information from another. Time Savings: spend up to 25% less time documenting Improved quality of care: can use protocols to automatically enter orders based on client's conditions. Embedded protocols enhance caregiver knowledge and the ability to follow clinical practice guidelines. Medical errors minimized by alerts. Data can be analyzed when collected, EHRs facilitate evidence-based practice. Information is private and safe: permanently stored, confidentiality is enhanced in several ways: tracking everyone who accesses chart, proper security clearances, unique passwords, restricted access, and using screen protectors.

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Disadvantages of Electronic Health Records

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Expense Downtime: downtime processes must be in place for times when parts of EHR are not available Difficulties associated with change: can be challenging and time consuming. Some healthcare providers see no reason to change and resist changing to EHR. Not always easy to capture narrative nursing content from paper into electronic format. Some EHRs not user friendly. Some systems do not control redundancy Lack of Integration: Most EHRs not integrated across diff. departments. Sometimes a person cannot see part of chart from their location.

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Advantages of Paper Health record

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Care providers comfortable with it because it is familiar. Do not require large databases and secure networks to function. No downtime for system changes, weather, etc. Relatively inexpensive to create new format and update old ones.

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Disadvantages of Paper Health Record

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Only one care provider can access the record at a time. Retrieving information may be slow: may need to search through multiple pages to find information. Documentation is time consuming: handwriting slower, often redundant and repetitive, paper records require manual audit of many charts to create reports and collect client date. High risk for patient care error: writing hard to read, papers can be lost or damaged. Storage of paper records is expensive. Confidentiality is difficult to protect.

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What is the goal of nursing documentation?

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A clear, concise representation of the client's healthcare experience that is easily accessible and understood by all members of the healthcare team.

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What does effective documentation enable use of?

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Effective documentation enables use of current and consistent data, problem statements, diagnoses, goals, and strategies to support continuity of care.

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What are some common formats for Nursing progress notes?

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Can take many forms, including paper, computerized electronic documents, audio or video files, emails, faxes, scanned paper documents, electronically stored photographs, xray findings, and other images.

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What influences your choice of format?

answer

Depending on the documentation model your organization selects, you may use one or more of the following charting formats. Also influenced by whether your nursing documentation is written on paper, captured and stored electronically, or in a blend of the two. In all formats, you must learn to use abbreviations appropriately.

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Joint Commission mandates that healthcare not use the following abbreviations. What is on "do not use" list?

answer

"U" or "u" for units. "IU" FOR international unit. Q.D., QD, q.d., qd (daily) Q.O.D., QOD, q.o.d., qod (every other day) Trailing zeros and lack of leading zeros MS, MSO4, AND MgSO4- could mean morphine sulfate or magnesium sulfate.

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What is under consideration for the "do not use" list:

answer

The symbols > and < for greater and less than All abbreviations for drug names Apothecary units (use metric units instead) The symbol @ (write "at" or "each") The abbreviation "cc" (write mL and milliliters) The abbreviation "ug" (write mcg or micrograms)

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ad lib

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as desired, if the patient desires

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AKA

answer

above knee amputation

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Amb

answer

Ambulation, ambulatory

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bid

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Twice a day

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BM

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bowel movement

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BR

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bedrest

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BRP

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bathrooom privileges

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BSC

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bedside commode

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c

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Calories

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Cath

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Catheter

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CBC

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Complete blood count

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CCU

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critical care unit or coronary care unit

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c/o

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complaint of

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CVA

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cerebrovascular accident (stroke)

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D&C

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Dilation and curettage

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DM

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Diabetes mellitus

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dsg or drsg

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Dressing

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EBL

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Estimated blood loss

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ED/ER

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Emergency department, emergency room

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EEG

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Electroencephalogram

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EENT

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eyes, ears, nose, throat

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ETOH

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Alcohol

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FBS

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Fasting blood sugar

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Fx

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fracture

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gtt(s)

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drops

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HA

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Headache

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HMO

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health maintenance organization

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h/o

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history of

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hob or HOB

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head of bed

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HOH

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Hard of hearing

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H&P

answer

History and physical

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HTN

answer

Hypertension

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Isol

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isolation

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IVP

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intravenous push (caution: do not use to mean "IV piggyback")

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LMP

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last menstrual period

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MD

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Medical doctor

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MN

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midnight

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NAS

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No added salt

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N/V/D

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Nausea, vomiting, diarrhea

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NKA or NKDA

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no known allergies or no know drug allergies

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NG

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nasogastric

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NGT

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nasogastric tube

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noc

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at night

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NPO

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nothing by mouth

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OB

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Obstetrics

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OOB

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out of bed

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OPD

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Outpatient department

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ortho

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orthopedics

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OR

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Operating room

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os

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Mouth, opening

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pc

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after meals

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PCA

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patient controlled analgesia

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P, p

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after

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PPBS

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postprandial blood sugar

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prn

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as needed

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q

answer

every

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qam

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every morning

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qh

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every hour

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qid

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four times a day

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s

answer

without

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SCD

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sequential compression device

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SOB

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short of breath

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ss

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one-half

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SSE

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soapsuds enema

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TO

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Telephone order

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TPR

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Temperature, pulse, respirations

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tid

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three times a day

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VO

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verbal order

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w/c

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wheelchair

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WNL

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within normal limits

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Narrative chart entry and goal

answer

used with written source-oriented and problem-oriented charts. Tells the story of the patient's experience in a chronological format. Goal is to track the client's changing health status and progress toward goals.

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When is Narrative charting useful?

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Useful when attempting to construct a time line of events, such as a cardiac arrest or other emergency situations.

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Problem-Intervention-Evaluation (PIE)

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Organizes information according to the patient's problems and requires keeping a daily assessment record and progress notes. This eliminates the need for seperate care plan and provides a nursing-focused rather than medical focused record.

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Explain use of each part of PIE

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Problem: uses data to identify nursing diagnoses. Intervention: Document the nursing actions you take for each nursing diagnosis. Evaluation: Document the patients response to interventions and treatments.

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SOAP/SOAPIE/SOAPIER

answer

The SOAP format is often used to write nursing and other progress notes. Can be used in source-oriented, problem-oriented, and electronic health records.

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Explain what SOAP(IER) stands for?

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Subjective data Objective data Assessment- usually patient problem or nursing diagnoses. Plan: Short term and long term goals and strategies that will be used. Interventions Evaluation:effectiveness of interventions Revision: Changes made to original care plan

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How does POR format relate to SOAP format?

answer

You will refer to and use the four parts of POR (database-not for SOAP-, problem list, initial plan, progress notes and discharge summary) when charting in SOAP format.

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Focus charting

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Uses assessment data to evaluate client care concerns, problems, or strengths. Identifies necessary revisions to the care plan as you document each entry.

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What is the focus on a Focus Chart?

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The focus is often a nursing diagnosis, a client behavior, a special need, an acute change in condition, or a significant event.

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When does Focus Charting work well?

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Focus charting works well in acute care setting s and in areas in which the same care and procedures are repeated frequently.

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What does Focus Charting consist of and look like?

answer

First column is time and date. Second column identifies the focus or problem addressed in the note. Third column contains charting in a DAR format.

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What is the DAR format?

answer

Acronym for Data, Action, and Response. Data-reflects the assessment phase of nursing process. Action-reflects the planning and implementation phases Response- reflects the evaluation phase

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FACT System

answer

Incorporates many CBE principles and includes four key elements: Flow sheets individualized to specific services Assessment features standardized to baseline parameters Concise, integrated progress notes and flow sheets documenting client's condition and responses Timely entries documented when care is given. Includes only exceptions to the norm or significant information about the patient.

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What forms do nurses use to document nursing care?

answer

Vary by purpose, institution, and unit. Regardless of system or forms used, nursing documentation reflects the nursing process.

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Kardex or Patient Care Summary

answer

Kardex is a special paper form or folding card that briefly summarizes a patient's status and plan of care. Paper Kardex and electronic patient care summaries typically pull patient data from multiple areas of the health record. Paper Kardex are usually kept together in a portable file in a central location in the nurses station to allow all team members access to patients' summary information.

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Occurrence Reports

answer

also called incident report, is a format record of an unusual occurrence or accident. Not part of the clients health record. Both used to track problems and identify areas for quality improvement and to create safe processes and procedures for clients and staff. You should report all errors, even if there was no adverse impact on the client.

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What could be in Occurrence report?

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Should clearly identify the client, date, time, and location. Briefly describe the incident in objective terms.

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What is unique about documentation in Home Healthcare?

answer

The Centers for Medicare & Medicaid Services (CMS) guidelines govern home healthcare documentation. Requirements for care are: certification of homebound status a plan of care and ongoing assessment of the need for skilled care.

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What does the Home healthcare documentation include?

answer

Assessment highlighting changes in the client's condition Interventions performed The client's response to interventions Any interaction or teaching that you conducted with caregivers Any interaction with the patient's primary care provider

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What is unique about documentation in long-term care?

answer

Documentation requirements for long-term care depend on the level of care the client requires. All facilities must have a comprehensive assessment done on each patient within 14 days of admission (federal law). MDS must be updated every 3 months. Legal requirements mandate that you report changes in a client's condition to primary care provider and the family.

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What is required if a patient is receiving Medicare-reimbursed services?

answer

Documentation is required during each shift and a summary written by nurse is needed weekly.

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What is included in a weekly summary?

answer

A summary of client's condition An evaluation of the client's ability to perform ADL's The client's level of consciousness and mood Hydration and nutrition status Response to medications Any treatment provided Safety measures

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When is intermediate-care services provided in a long-term care facility and what will be needed for these clients?

answer

It is provided when a client needs assistance with medications, nutrition, and ADLs. These clients require a nursing care summary every 2 weeks.

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What do EHR's (electronic health records) promote, improve, or help do?

answer

EHR's promote efficient use of nurses' time, improve interdisciplinary collaboration, streamline processes, make procedures more accurate and efficient, and ensure improved patient safety and care outcomes.

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What is the purpose of giving an oral report?

answer

The purpose of giving an oral report is to maintain continuity of care.

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What does an oral report provide?

answer

The oral report provides an opportunity for professional communication that assists in organizing your work and also for learning, building team relationships, and collaborating to improve patient care.

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What does the quality of a report influence?

answer

The quality of the report you give or receive influences how you and others plan the day or night's work

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What is the purpose of a handoff (also called change-of-shift or handover) report?

answer

The purpose of a hand off report is to alert the next caregiver about the client's status or recent changes in the client's condition and to discuss planned activities, tests, procedures, or concerns that require follow-up.

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When, where, and how is a handoff report given?

answer

A handoff report may be given at the bedside or in a conference room using paper notes or a mobile or desktop EHR device at the end of one nurses' shift and beginning of another. They are usually given orally.

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Bedside report

answer

sometimes known as "walking rounds", allows you to observe patient. Outgoing nurse can introduce you to client and it gives patient opportunity to participate in the report.

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Face-to-face report

answer

may involve outgoing and oncoming nurse or entire oncoming shift. Time efficient and allows interaction among nurses.

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Audio-recorded report

answer

Can be time consuming, can't ask nurse questions, and cause issues if report is hard to hear.

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What does the Joint Commission recommend with handoff report method?

answer

Joint Commission recommends using a method that allows for questioning between the giver and receiver of the information.

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What is the PACE format?

answer

an example of a standardized approach. Stands for Patient/Problem, Assessment/Actions, Continuing/Changes. and Evaluation.

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What is the SBAR?

answer

SBAR- Situation-Background-Assessment-Recommendation. An easy to remember, concrete acronym useful for framing conversations, especially interdisciplinary communication. Allows for an easy and focused way to set expectations for what will be communicated and how between members of team.

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What data should be included in a handoff report?

answer

Will always include: Client progress made during your shift, therapies and treatments administered, teaching done, consultations done or planned with other disciplines, status of identified desired outcomes, any changes in client status, progress made on discharge planning

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What should be used for all types of oral reports?

answer

Remember the acronym CUBAN Confidential-Uninterrupted-Brief-Accurate-Named nurse Use a standardized format (ex. PACE, SBAR)

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P in Pace. What should be included?

answer

Include patient's name, room number, diagnosis, reason for admission, and recent procedures. State the present problem. Briefly summarize medical history relevant to current problem.

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A in Pace. What should be included?

answer

Nursing assessments and interventions directed to the problem, including teaching done and status of discharge planning.

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C in Pace. What should be included?

answer

Continuing needs and potential changes include the following: Patient care and treatments that must be monitored on other shifts Changes in the patient's condition or the care plan, recent or anticipated

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E in Pace. What should be included?

answer

Evaluation of responses to nursing and medical interventions, progress toward, goals, and effectiveness of the plan

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What should you do when your handoff report is finished?

answer

Ask the receiving nurse if he has any questions. Get the nurse's full name, and then record it plus the transfer date and time in your transfer documentation.

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How should you start each part of SBAR?

answer

Identify yourself, the patient, and the agency. Situation-"Here's the situation.." Background- "The support background information is..." Assessment-"My assessment of the situation is that..." Recommendation- "I recommend that you..."

question

What is a transfer report?

answer

Transfer reports are reports given when a patient is transferred form unit to unit or facility to facility. If patient is being transported to another unit in the same facility, you will need to transport a paper chart with the patient.

question

How do I receive and document verbal and telephone orders?

answer

The Joint Commission says that to best avoid the dangers you should "verify the complete order and test result by having the person receiving the information record and 'read-back' the complete order or test result".

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When are telephone orders acceptable?

answer

Acceptable when there has been a sudden change for the worse in the patient's condition and the client's primary care provider is not in the hospital, or does not have access to placing orders electronically outside the hospital. Also acceptable in life-threatening emergency, but must apply the "read-back" safeguard.

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What should be done when writing a telephone or verbal order onto a paper order?

answer

First document the date and time, Next write the text of the order. Following the text of the order, depending on how you received the order write "TO" (telephone order) or "VO" (verbal order), followed by the ordering provider's name and then your name.

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What should be done if a prescription is entered electronically?

answer

Indicate during the order entry that it was given verbally or over the telephone, the date and time the order was given, and then search for and select the prescriber's name. Click "sign" or whatever option in your EHR indicates the order is sgned and is now active.

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What is a verbal order?

answer

Verbal orders are spoken directions for patient care given to you in person, usually during an emergency situation. Providers should never use verbal orders as a routine method of communicating orders.

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When should you document?

answer

After care or assessment Beginning of shift Chronologically, to communicate changing status (document times in order) Never chart ahead (before performing an intervention) Avoid "block" charting (ex.from 1300 to 1500) Late entries, paper. (add late entries to first avail. line. Record date and time you are charting, but in the body, clearly designate that it is a late entry.) Late entries, EHR. (Open appropriate form and change the auto. generated date and time then sign)

question

What should you document?

answer

Document condition of patient, assessments and interventions performed, any abnormalities, the patient response to interventions towards goal.

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How should you document?

answer

Record data accurately, use neutral, nonjudgmental language, avoid vague, subjective words (ex. good, average), use only the abbreviations authorized by your organization, use correct spelling and grammar, date and time all your notes accurately, use of restraints, occurrences such as falls and medication errors, complete data about medications, unscheduled, prn, IV infusions, and STAT medications.

question

Can I delegate charting?

answer

Though NAP's can chart ADLs, activity, and I&O on a graphic chart, you are responsible for charting any nursing actions you provide. Never chart the actions of others as though you performed them.

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What are the key differences in the organization of source-oriented records, problem-oriented records (PORs), electronic documentation systems, and CBE systems?

answer

The source-oriented record is organized according to discipline. Each discipline charts in its defined section of the chart. The problem-oriented record is organized around a patient problem list. All disciplines chart on shared notes that are referenced to the identified problem. The EHR can contain both source-oriented and problem-oriented records. In a CBE system only significant findings or exceptions to standards and norms of care are charted. CBE uses preprinted flow sheets to document most aspects of care, and it assumes that unless a separate entry has been made (an exception), all standards have been met, prescribed care has been done, and the patient has responded normally. Normal responses for various assessments are defined on the form.

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How do home care and long-term care documentation differ from hospital-based documentation?

answer

here are the following differences from hospital-based documentation: Home care documentation must include (a) certification of homebound status, (b) ongoing assessment of the need for skilled care, (c) use of the OASIS data set, and (d) a monthly summary describing the patient's status and ongoing needs. The patient's physician signs this form, and this is submitted for reimbursement. Long-term care documentation must include (a) a comprehensive assessment using the Minimum Data Set for Resident Assessment and Care Screening (MDS) within 4 days of admission and updates every 3 months with any significant change in client condition, (b) a report of any changes in a client's condition to the primary care provider and the client's family, and (c) a summary by an LVN/LPN or RN either weekly for clients receiving skilled services or every 2 weeks for clients receiving intermediate care services.

question

Identify at least five types of paper documentation forms.

answer

There are many types of documentation forms. Among them are nursing admission data forms, discharge summaries, flow sheets, graphic records, checklists, intake and output records, medication administration records, Kardexes or patient care summaries, integrated plans of care (IPOCs), and occurrence reports. Occurrence forms and the Kardex® are not part of the patient record and as such are not charting forms. They are used to document unusual events (occurrence forms) or to summarize care (Kardex®).

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What should you document after administering a prn medication?

answer

After administering a PRN medication, document the time and date the medication was given and the location of administration if the medication was injected on the medication administration record (MAR). In the nurses' notes, state the reason for administering the medicine, the amount given, and the patient's response to the medication.

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What is the purpose of an occurrence report?

answer

An occurrence report is a formal record of an unusual occurrence or accident. This is an agency report and is not part of the patient's chart. An occurrence report is filed in many circumstances. Examples of reportable events include falls or other patient injury, loss of patient belongings, or administration of the wrong medicine. Occurrence forms are used to track problems and identify areas for quality improvement.

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What important factors should you document when receiving a telephone order?

answer

The following are guidelines for telephone orders: Only write the prescription if you heard it yourself; no third-party involvement is acceptable. Repeat the prescription even if you believe you understood it entirely. Spell unfamiliar names using a system like "B as in boy." Pronounce digits of numbers separately; for example, instead of "seventeen" say "one, seven." Make sure the verbal orders make sense with the patient's status. If possible, have a second nurse listen to the prescription to verify accuracy. Directly transcribe the prescription onto the chart. Transcribing it onto a piece of paper and then copying it again introduces another chance of error. When writing the prescription, first document the date and time. Then write the text of the prescription. Following the text of the order, document "T.O." followed by the ordering provider's name before yours. Be sure you have the phone number of the provider to allow access if future questions arise. The physician must countersign all verbal and phone orders within 24 hours.

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What aspects of care should be documented?

answer

The following aspects of care should be documented: Routine care Assessment data Any significant events or changes in condition If informed consent is obtained Any occurrences Calls to the primary care provider Teaching performed Use of restraints Refusal of medicines or treatments Patient's spiritual concerns

question

How is documentation on paper different than documentation in an EHR or on an electronic digital form?

answer

Although the same principles apply, there are some differences. When you document electronically, the information is immediately available to other care providers in other settings. You do not have to wait for another provider to finish with the chart, so you can chart almost immediately after patient contact. Usually, you will not type in a narrative note but will enter a phrase or click to bring up a screen. After that, you check or indicate certain words or fields that then bring up other screens and other choices. You will struggle less with phrasing and terminology because the computer provides lists from which you choose those applicable to your patient and your interventions.

question

You are a student nurse on a medical-surgical unit. You review your client's chart and notice that the physician has entered orders that do not appear to be appropriate for your client. The physician is still in the area. How would you handle this situation?

answer

As a student nurse, you may wish to discuss the situation with your clinical instructor or the staff nurse assigned to the patient. The physician who wrote the orders must be contacted directly to question the orders. Explain your concerns objectively. If the order still stands, you may refuse to carry out the order, but you will need to go through the chain of command on the unit to do so.

question

Charting by exception: A. is a reliable form of documentation, minimizing errors. B. should be used only in ambulatory clinics and long-term care facilities. C. increases the risk of liability in malpractice cases because "not documented, not done." D. can be used to document care accurately on stable patients.

answer

D. can be used to document care accurately on stable patients.

question

When reviewing your documentation of a patient, it should reflect: A. everything that could have been done during your shift. B. objective, comprehensive, accurate account of patient data, nursing care provided, and patient response. C. all the procedures, medications, and tasks that were done that day. D. a detailed narrative account of what occurred moment by moment that shift.

answer

B. objective, comprehensive, accurate account of patient data, nursing care provided, and patient response.

question

Documentation of nursing care for home health patients requires which of the following? Choose all that are correct. A. Certification of homebound status B. Use of the OASIS data set C. A weekly summary describing the patient's status and ongoing needs D. Ongoing assessment of need for skilled nursing care

answer

A, B, D

question

The use of abbreviations is a common practice in healthcare. The use of abbreviations contributes to which of the following? A. Decreased efficiency in documentation B. Increased risk for medical errors C. Uniform use in all facilities D. Ease in understanding physician orders

answer

B. Increased risk for medical errors

question

Identify five components of nursing documentation that demonstrate quality care that is legally defensible.

answer

Any five of the following components are an acceptable answer: Legibility Patient's name, information, and date are on each sheet No blank spaces between entries Accurate and objective Errors lined out and initialed No correction fluid or "inking over" the error Signature of the care provider and his title Late entries clearly noted

question

List the important factors to document when taking a physician's verbal order:

answer

For verbal orders, the following factors are important to document: Only write the prescription if you heard it yourself; no third-party involvement is acceptable. Repeat the prescription even if you believe you understood it entirely. Spell unfamiliar names using a system like "B as in boy." Pronounce digits of numbers separately; for example, instead of "seventeen" say "one, seven." Make sure the verbal orders make sense with the patient's status. If possible, have a second nurse listen to the order to verify accuracy. Directly transcribe the prescription the possibility of error. When writing the prescription, first document the date and time. Then write the text of the prescription. Following the text of the order, document "T.O." followed by the ordering provider's name before yours. Be sure you have the phone number of the provider to allow access if future questions arise. The physician must countersign all verbal and phone orders within 24 hours.

question

Which of the following incidents requires the nurse to complete an occurrence report? 1) Medication given 30 minutes after scheduled dose time 2) Patient's dentures lost after transfer 3) Worn electrical cord discovered on an IV infusion pump 4) Prescription without the route of administration

answer

2) Patient's dentures lost after transfer

question

The nurse is orienting a new nurse to the unit and reviews source-oriented charting. Which statement by the nurse best describes source-oriented charting? Source-oriented charting 1) Separates the health record according to discipline 2) Organizes documentation around the patient's problems 3) Highlights the patient's concerns, problems, and strengths 4) Is designed to streamline documentation

answer

1) Separates the health record according to discipline

question

When the nurse completes the patient's admission nursing database, the patient reports that he does not have any allergies. Which acceptable medical abbreviation can the nurse use to document this finding? 1) NA 2) NDA 3) NKA 4) NPO

answer

3) NKA

question

The nurse is working on a unit that uses nursing assessment flow sheets. Which statement best describes this form of charting? Nursing assessment flow sheets 1) Are comprehensive charting forms that integrate assessments and nursing actions 2) Contain only graphic information, such as I&O, vital signs, and medication administration 3) Are used to record routine aspects of care; they do not contain assessment data 4) Contain vital data collected upon admission, which can be compared with newly collected data

answer

1) Are comprehensive charting forms that integrate assessments and nursing actions

question

The client asks the nurse why an electronic health record (EHR) system is being used. Which response by the nurse indicates an understanding of the rationale for an EHR system? 1) It includes organizational reports of unusual occurrences that are not part of the client's record. 2) This type of system consists of combined documentation and daily care plans. 3) It improves interdisciplinary collaboration that improves efficiency in procedures. 4) This type of system tracks medication administration and usage over 24 hours.

answer

3) It improves interdisciplinary collaboration that improves efficiency in procedures.

question

At the end of the shift, the nurse realizes that she forgot to document a dressing change that she performed for a patient. Which action should the nurse take? 1) Complete an occurrence report before leaving. 2) Do nothing; the next nurse will document it was done. 3) Write the note of the dressing change into an earlier note. 4) Make a late entry as an addition to the narrative notes.

answer

4) Make a late entry as an addition to the narrative notes.

Ch. 18: Documenting and Reporting – Flashcards

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