Ch 26 Documentation and Informatics – Flashcards

1, 2, 3 Records must be accurate, factual, and objective. Errors in recording can lead to errors in treatment or may imply an attempt to mislead or hide evidence. You are accountable for the information that you enter into a patient's record. Critical statements can be used as evidence for nonprofessional behavior or poor quality of care. Using shorthand is not recommended because, if the charting became illegible, it might appear as if the nurse attempted to hide information or deface a written record.

3 An assessment process that includes subjective and objective data is not included in the PIE charting format. PIE charting includes only the problem, the necessary intervention, and an effective outcome. Focus charting follows a data, action, and response (DAR) format. This format reflects various steps of the nursing process. SOAP and PIE charting are similar in their problem-oriented nature. However, the SOAP format originated from the medical records and PIE charting has a nursing origin. The verbalizations of the patient are included under the subjective data in the SOAP format.

1, 3, 4 Records must be complete, accurate, and factual. They should convey that the patient received adequate care. Illegible writing can be misinterpreted. Using black ink will appear more legibly when the document is scanned or photocopied. The inclusion of the date and time ensures a correct order of the care provided. A signature indicates the person who was responsible for the care. The correction fluid should not be used to correct errors in documentation. The error should be corrected by drawing a single line through the error and writing the word error above it. Another person can fill in incorrect information if there are blank spaces in the nurse's notes.

4, 5 Documenting specific objective data, such as heart rate of 75/minute and temperature 102 degrees Fahrenheit along with specific subjective data such as a 7/10 pain scale are accurate examples of documentation. The nursing record states the details very clearly and is not open to interpretation. It includes both objective and subjective data, because the intensity of the pain is reported by the patient. The reason for giving the tablet for pain is not mentioned. In addition, the spelling of the name of the medication is wrong, giving an impression of carelessness. The reason for starting the IV and its location is not mentioned. The documentation should clearly indicate the details. The statement, "Pain seems to be reduced," is an assumption and not validated subjective data such as the patient's statement or pain scale report.

3, 4 The expanded form of the SOAP note format is S for subjective, O for objective, A is for assessment, and P is for plan. Intervention, order, and problem are not elements of a SOAP note. The PIE note contains intervention and problem.

3 Hand-off reports are prepared any time patient care is transferred from one caregiver to another in the healthcare setting. The report prepared during a shift change is also a hand-off report. A discharge summary is the summary of the patient's hospital stay, condition at discharge, diagnosis, prognosis, and treatment plan and goals. An incident report records any incident happening that is inconsistent with the routine care of a patient or with the routine operation of a health care unit, such as a fall or injury from medical equipment. A telephone report is made when the nurse reports any significant changes in the patient's health condition to the healthcare provider or other medical personnel.

3 Transfer reports are the types of hand-off reports used when patients are transferred from one unit to another. Referrals are made when the patient requires the services provided by another caregiver for a different category of health needs. Change-of-shift reports are handed over during the shift changes between nursing staff. A discharge summary is a report format used upon discharge of the patient. It contains the patient's discharge diagnosis, prognosis, and treatment plan.

1 CPOE eliminates the need for someone to transcribe the orders because it allows the provider to enter the order directly; therefore, CPOE reduces transcription errors. CPOE does not necessarily reduce the amount of time it would take a healthcare provider to write a safe and accurate order. CPOE should not decrease communication within the interprofessional team. Orders should only be written on secure networks to ensure patient privacy.

2 Objective data refers to the information that is directly observed or measured by the recording personnel. In this case, the nurse observes that the patient's incision site is clean without any purulent discharge or erythema. Subjective data are recorded by documenting the exact words spoken by the patient in quotation marks. Any instructions regarding the nursing process, treatment, and medication administration would fall under the plan header. The need for changing the dressing every day and continuation of the antibiotics would be part of the plan in the SOAP format.

2, 3, 5 Objective data are data that are observed and measured directly by the healthcare professional. Blood pressure can be measured through a sphygmomanometer. The characteristics of phlegm can be observed. The wheezing and rhonchi can be auscultated. Chest pain and pain radiating to the arm are the verbal complaints of the patient. These are considered subjective data.

2 Patients have the right to read their medical records, but the nurse should always know the facility policy regarding personal access to medical records because some require a nurse manager or other official to be present to answer questions about what is in the record. Families may read the records only when the patient has given permission.

1, 3, 4, 5 Documentation errors such as failing to mention drug allergies, information on discontinued medications, or a history of cancer can result in serious treatment errors and bad outcomes. This results in malpractice lawsuits. Recording information with incomprehensible writing also leads to errors and consequent lawsuits. Failing to record the number of siblings of the patient does not reflect the health status of the patient; it does not affect the treatment delivered.

2 In order to determine healthcare reimbursements that have to be provided for the patient, insurance companies have to first determine the diagnosis-related group (DRG) of the patient. This can be done by referring to the patient's documented reports. Thus, it is very important that the information pertaining to the patient's health is well documented. Insurance companies do not provide preventive care to patients; preventive care is given by the provider. The amount that has to be paid for a premium is fixed and is not related to the patient's interventions. Proper documentation is not helpful in reducing the cost of healthcare services provided to the patient.

1, 3, 4 A proper way of documenting is recording the pertinent health and drug information that has been given to the patient. For a proper documentation, the medications and the drug reactions that a patient has need to be recorded. The records should also mention the medications that have been discontinued. Using a white-out correction fluid to correct errors indicates that the nurse is hiding information or defacing a written record. Instead, striking the information is the correct technique. Spaces should not be left in nursing notes, because others may add incorrect information in the blank spaces. Signing with a surname is important, because it identifies the person responsible for the patient's care.

4 The patient's admission sheet contains the patient's demographic data such as name, address, contact numbers, age, date of birth, insurance, employment, and information about the guardian. The nurse accesses this to obtain the contact number of the patient's guardian. The discharge summary is the summary of the patient's hospital stay, condition, and treatment plan at the time of discharge. The nurse's admission assessment consists of the patient's health-related information. It contains the patient's history and notes from the physical examination conducted by the nurse when the patient was admitted. The nurse's notes record the nursing process throughout the course of treatment.

1 Charting by exception uses forms that have predefined normal findings. The nurse only documents findings that not standard. Unless documented, all other findings are assumed to be normal. Charting is recording or updating a patient's chart. The DAR report consists of an elaborate description of the patient's concerns, signs and symptoms, condition, nursing diagnosis, behavior, significant events, or change in a patient's condition. The PIE report documents problem—intervention—an evaluation and is not narrative. A narrative report is documentation of information in a narrative format.

1, 2, 5 The report is a description of an incident such as a fall causing injury. Analysis of the incident or an occurrence report helps to identify the trends of the system or unit operation of the healthcare system. This helps in patient safety and quality improvement. It helps to identify the need to change procedures, services, or the infrastructure of a healthcare facility. It is an important part of the quality improvement program. The negative feedback of the patient regarding healthcare delivery is not recorded in the incident report. The incident report is not used to determine the severity of punishment to be applied to the person who is responsible for that incident.

1, 3 SOAP charting originated from medical records, whereas PIE charting has a nursing origin. The SOAP chart includes both types of assessment data: subjective and objective. The PIE chart does not include assessment data. A nurse's daily assessment data are charted on a separate sheet. Both chart forms are based on a patient's problems. Both chart types have notes numbered based on a patient's problems. Both the charts are structured into various sections.

1, 2, 3 The patient's medical record needs an accurate description of the patient's health status. The information needs to be legible. The chart has a list of all the medications that are given during present care, any discontinued medications, and the drug allergies of the patient. It is not required or essential to mention the drug manufacturer or the size, shape, and color of the pills given. Information about the drug manufacturer is not related to the patient's health. The shape, size, and color of the pills do not have the potential to affect the patient's health or care.

2, 3, 5 Proper discharge planning is important to prepare patients for an effective and timely discharge from a healthcare institution. This is necessary to facilitate cost savings and ensure reimbursement. Contact information of the healthcare providers is documented to help the patients contact them when needed. Step-by-step instructions about the procedures should be provided so that the patient can refer to them while doing self-care procedures. Warning signs and symptoms that require the healthcare providers' attention should be documented in the discharge summary. Detailed biographical information of the patient and all the investigations done during the period of hospitalization are not required to be documented in a discharge summary.

2 HIPAA protects the patient's privacy regarding health information and governs the management of patient information. The illegal exchange of the patient's health information violates this act. ARRA encourages electronic communication among the health care bodies and mandates that all medical records are to be kept electronically from 2014 forward. HITECH rewards the primary healthcare provider and facilities that adopt the electronic medical record (EMR)/electronic health record (EHR). The TJC act does not exist.

2, 3, 4, 5 Effective documentation minimizes the risk of errors, saves time for the primary healthcare providers, and ensures continuity of care. It also protects the nurse from legal issues during mishaps. Documentation clarifies the type of treatment a patient receives and supports reimbursement to the health care agency.

2 This is an example of an electronic health record. The electronic health record is an electronic record of patient health information generated whenever a patient accesses medical care in any healthcare delivery setting. In this system, you are able to access information about the patient during the current hospitalization and from four previous times when the patient accessed care. Information technology and personal health information are not a type of record system. The administration information systems support the effective use of information technology.

3 A clinical decision support system helps the primary healthcare providers and nurses to make informed clinical decisions. This system gives alerts, warnings, and other critical information about the patient to the user. It helps to decrease the treatment errors, resulting in quality patient care. An administrative information system is the computerized storage of all administrative information (such as health care finances, scheduling of treatments, admission, and discharge) in a healthcare facility. A computerized provider order entry allows the primary healthcare providers to directly put orders in the information system from which the nurses can access the information and carry out the orders. A clinical information system is a computerized program dealing with a patient's health-related information that is useful for the primary healthcare providers in a health care setting.

1, 2, 4 The documentation made by the nurse should conform to the standards of the Joint Commission and the National Committee of Quality Assurance (NCQA). The documentation ensures that the standards of care are maintained to uphold institutional accreditation and minimize liability. The American Nursing Association (ANA) sets standards to provide safe, effective, patient-centered, timely, efficient care to the patient. The diagnosis-related groups help to reimburse for patient care. The Health Insurance Portability and Accountability Act (HIPAA) is the legislation that protects the patient's right to privacy of health information.

3, 4 The exchange of information amongst the healthcare team members is done through written reports and oral communication. Pictures of patients are not used in routine communication, but they may be used by specialists like dermatologists and plastic surgeons. The patient's health information is not exchanged through a thesis or electronic cards.

3 A clinical decision support system is based on rules that are triggered by data entry. When certain rules are not met, alerts, warnings, or other information may be provided to the user.

2, 3, 4 Charting by exception focuses on documenting deviations from established norms. It is a shorthand method for documenting records, which saves time. It only focuses on documenting significant findings, because it assumes that all standards are met unless they are documented. Documenting patient concerns is a type of document, action (or nursing intervention) response (DAR) progress note, which is a type of narrative format. Including a subjective assessment in a progress note is a type of SOAP format of narrative charting.

4 The answer that describes the patient's actions and heart rate before and after exercise provides the most accurate, objective information for the chart. The other choices are not specific enough and do not give enough objective information.

1, 2, 3 At the time of discharge, a patient should be provided with a discharge summary form in which home care is noted. Dietary restrictions, follow-up care, and emergency contact numbers should be included in the discharge summary forms. Preoperative instructions are given before surgical procedures. Acuity records determine hours of care and staff required to care for the patient.

3, 4, 5 Electronic health records integrate all the pertinent patient information into one record regardless of the number of times the patient visits the healthcare provider. Electronic records perform checks for regulatory requirements and provide a means to compare ongoing clinical data with baseline information. The tendency to be repetitious is associated with narrative documentation. Electronic health records are not time consuming because they are electronic.

4 A flow sheet is utilized when repeated observations are to be recorded in a quick and accurate manner. The information from a flow sheet is retrieved quickly, too. An admission sheet is used to record the detailed initial assessment at the time of admission. An operative report records the summary of the patient's surgery, complications, and preoperative and postoperative diagnoses. The physician's order sheet contains the information of the physician's orders for treatment and medications with date, time, and signature.

2 A newly ordered medication must always be entered into the patient's medical record prior to the medication being administered. This process ensures that a pharmacist reviews the order prior to dispensing the medication as a safeguard against medication errors. Using SBAR as a standardized format for providing the report decreases the chances of a medical error occurring due to breakdowns in communication. The orders taken should always be read back to the provider to ensure accuracy of information. Asking the preceptor to listen in on the conversation is a good idea if it can be done logistically.

2, 4, 5 Good quality documentation should be factual, accurate, current, complete, and organized. Using the word seems indicates that the nurse is not communicating a fact but rather, stating her opinion. "Sounds are produced" are terms that indicate the nurse lacks knowledge. It should be written as "wheezing is present while exhaling." By documenting "copious amounts," the nurse is not providing a detailed enough description of the amount, color, and consistency of the sputum. The statement about the vital signs has all the required information accurately documented. Recording the presence of rhonchi in the lower bases of the lungs on auscultation is also a correct statement.

1, 2 Using the problem-oriented medical record (POMR) method of documentation, four major sections are maintained, namely the database, problem list, care plan, and progress notes. The problem list contains all the patient's problems in chronological order. The information about the new sign and the recovery from the previous illness is recorded in the problem list in the following manner: The new problem (acid reflux) is added to the problem list, the solved problem (typhoid) is highlighted, and the date of resolution is added. New problems are not to be highlighted. Progress notes should not be removed from the medical record. A new admission assessment is not required for a new problem when the patient is still in the hospital.

4 "The patient stated that he felt frustrated by the lack of information he received regarding his tests" is a nonjudgmental statement regarding the nurse's observations about the patient. Statements about the patient being defiant or demanding are judgmental, and information in the medical record should be factual and nonjudgmental. The statement about the patient appearing to be upset needs to be more specific regarding the reason for the patient's concern.

1, 4, 5 The patient's nursing diagnosis is an important component of the hand-off report because it guides the nursing care provided to the patient. Information about family members should be included in the report. It makes it easy to call them if required. Documentation of recent changes in the patient's condition is important, because the patient's condition may change the course of care provided to the patient. Routine care procedures like checking the IV site every 2 hours for signs of infection or infiltration should not be included in the hand-off report. The biographical information of the patient need not be included, because it is already available in the written form.

4 Nurses should enter only objective and factual information about patients. Opinions have no place in the medical record. Because the information has already been entered and is not incorrect, it should be left on the record. Never use correction fluid in a written medical record.

1 Any unexpected outcome of a procedure, unmet goals, or an intervention not indicated in the critical pathway is called a variance. A positive variance is a positive, unexpected outcome, such as when a patient starts walking a day earlier than expected after surgery. There is no negative variance term that is used in documentation. A low-grade temperature is not a life-threatening sign in this patient, and thus cannot be considered as a critical finding.

1, 2, 3, 4 After confirming the patient's name, room number, and diagnosis, the nurse should always document when he or she administers a medication. Administering the morphine without documenting it would be inappropriate. When orders are given by telephone, the nurse carefully notes the prescription and reads it back to the primary healthcare provider for verification. In the report, the nurse indicates whether it is a telephone order (TO) or verbal order (VO) and mentions the name of the patient, complete ordering information, name of the primary healthcare provider, and date and time of the TO or VO; the nurse also documents the order was read back to provider. This is signed by the ordering primary healthcare provider within a set time frame. The nurse does not just write that the medications were administered "as per orders." The telephone orders are discretely and carefully documented with specific information such as the date, time, patient, and the primary healthcare provider's name. Vague documentation and informatics can lead to misinterpretation and legal claims.

4 The patient's admission sheet contains the patient's demographic data such as name, address, contact numbers, age, date of birth, insurance, employment, and information about the guardian. The nurse accesses this to obtain the contact number of the patient's guardian. The discharge summary is the summary of the patient's hospital stay, condition, and treatment plan at the time of discharge. The nurse's admission assessment consists of the patient's health-related information. It contains the patient's history and notes from the physical examination conducted by the nurse when the patient was admitted. The nurse's notes record the nursing process throughout the course of treatment.

3 According to HIPAA regulations, any patient information should remain confidential. Therefore, patient information should never be printed for personal use. HIPAA allows access to electronic health records through user login information to ensure confidentiality and security. The main criterion of HIPAA regulations is to protect the health care information of the patient. At the same time, gaining access to the health information is possible by obtaining written permission from the patient.

4 The nurse should not leave blank spaces while recording the patient's health information, because another person may add incorrect information in the blank spaces. The nurse should draw a horizontal line in the space with his or her signature at the end to avoid this potential issue. The nurse should avoid using generalized, empty phrases such as "had a good day," which do not provide any information. Errors should not be erased, because doing so may indicate that the nurse is hiding some evidence. Errors should be scratched out with a single line, and the nurse should sign and date it. Black ink is more legible when records are photocopied or scanned, and illegible entries may lead to misinterpretations.

1, 4, 5 SOAP charting is one of the methods by which nurses monitor and record the progress of a patient's problem. In the SOAP charting, S stands for subjective assessment where the remarks of the patient are noted. The O stands for objective data, which can be measured and observed by the nurse during the treatment. The A stands for assessment, which refers to the diagnosis based on the data observed. The P stands for the plan of action to be taken. Here, the objective data include temperature, respiratory rate, and heart rate, all of which can be measured. Subjective data include discomfort and the inability to turn to the side; these cannot be measured.

2 Patients need to be able to understand information that you provide to them; ensure that written instructions are provided at a level that matches the patient's reading ability.

1, 2, 5 During change of shift report, include essential background information such as the patient's name, age, diagnosis, and allergies. Also include the response to treatments such as the response to pain-relieving measures. Information about how much the patient ate for breakfast is not necessary. This information is in the chart if the nurse really needs to know. Do not include critical comments about your patients.