Chapter 7 Assessment and Documentation for Optimal Care – Flashcards

-Is more complex -Is more detailed -Is longer to perform

Biological, Psychosocial, and functional information

-Sexual Fx -Depression -Incontinence -Alcoholism -Hearing Loss -Oral Health -Environmental safety

-Listen patiently -Allow for pauses -Ask questions not often asked -know normal changes

-Self-rapport -Report-by-proxy -Observation

-Conduct at a time when the client is at his or her best - Avoid biasing the response -Explore more only if necessary

Face to face approach with the client or a review of the client's written hx

-Medical Hx -ROS -Med Hx -Nutritional Hx -Factors that influence the person's quality of life

-Time consuming -Begins the moment the nurse sees the person -Perform a problem assessment first because of the length of time it takes to conduct an assessment

Fluids Aeration Nutrition Communication Activity Pain Elimination Socialization

State of hydration

Respiratory fx

Type and amount of food consumed

Adequate ability to communicate his or her needs

Ability to meet basic needs of toileting, grooming, and meal preparation

Physical, psychological, or spiritual pain

Difficulty with bladder or bowel elimination

Ability to give and recieve love and freindship

-An increase in chronological age has resulted in an increased rate of dementing illness -Assess cog and mood

These conditions provide a snapshot of a patient's overall health and the quality of care based on six "marker" conditions or "geriatric vital signs". It is an overview of a patient's response to the care given and point to the need for a more detailed assessment when necessary. It is an alert system and refers to only the most frequently-occurring health problems of older adults. S is for Sleep Disorders P is for Problems with Bathing or Feeding, I Incontinence C is for Confusion E is for Evidence of Falls S is for Skin Breakdown

Mini-Mental State Examination -Clock Drawing Test -The Mini-Cog

Geriatric Depression Scale

-Identifying areas where help is needed -Assisting in the determination of a need

"The client is active and independent and denies functional difficulties?"

Activities of Daily Living

Eating Toileting Ambulation Bathing Dressing Grooming

House Cleaning Shopping Managing Money

-Katz Index -Barthel Index -Functional Index Measure

-Promote healthy aging -Collect data and organize data -Each tool has strengths and weaknesses

OASIS include pertinent information personalizing the care provided

-Several Forms off documentation are available -Know the institution documentation preference

ANS: B Although providing a defense in the event of a possible lawsuit should not be the primary motive for the nurse to keep accurate and thorough documentation, doing so is the best defense in the event of legal action against anyone involved in a patient's care. Enabling the team to provide care that meets individual needs is a primary reason; documentation is necessary to ensure that the team has accurate and complete information about the resident's specific conditions. Enabling the patient to receive consistent care is a primary reason; documentation enables nurses on later shifts to be aware of conditions that have developed and the actions that have been taken on previous shifts. Providing the basis for reimbursement is a primary reason; the use of standard documentation in applying for reimbursement is a matter of law.

ANS: D SOAP stands for subjective (patient complaint), objective (observed data), assessment, and plan. A SOAP note is a record of an event in which a patient makes a subjective complaint and the nurse observes objective data, makes an assessment on the basis of the complaint and the data, and makes a plan for interventions based on the assessment. A SOAP note is a record in human language describing a problem, its assessment, and planned interventions.

ANS: A Entering patients' expressed wishes in the medical or clinical record helps ensure that the interdisciplinary team respects these wishes. According to regulations after the enactment of the Health Insurance Portability and Accountability Act (HIPAA), the patient has access to his or her own medical records and may designate others to have access. The OASIS is used to measure outcomes for quality improvement purposes; it does not contain all of the necessary information for care, such as vital signs. The MDS should be completed jointly by all members of the interdisciplinary team.

ANS: A The RAI must be completed for all residents receiving Medicare or Medicaid. The HIPAA was passed in 1996 and mandates privacy practices. The OASIS is an assessment designed for use in the home health care setting. Fulmer SPICES is an overall assessment tool developed in 2007.

ANS: A The major reason that documentation of this patient's health care must be accurate and complete is that she has complex health care needs in multiple settings and experiences a high risk for iatrogenic problems and high reimbursement expenses. The duration of her care is likely to be lengthy; the sternal wound infection after CABG is serious because of the potential for sternal osteomyelitis. In addition, individuals with diabetes are at high risk for infection and are slow to heal. The complexity of her care includes receiving care in multiple settings—at home, at dialysis, and in primary care for postdischarge follow-up care. For an older adult with diabetes, coronary artery disease, renal failure, and a serious infection, each facet of her health care depends on complete and accurate data on the other aspects of her care to help her achieve optimal health and wellness. This older adult is at risk for iatrogenic problems because of the complexity of her care. Each type of care, each illness or condition, and each setting exposes this older adult to a separate set of risks. In addition, individuals with diabetes can have peripheral neuropathies that increase the risk for falls and injuries. This older adult incurs health care expenses dealing with complex health care requirements including a recent hospital stay for surgery and complicated by an infection, ongoing needs for hemodialysis, and home care. Because much of the care is nurse driven, documentation is the basis for which reimbursement is provided.

ANS: A The nurse verifies the patient's identify to avoid computer errors before proceeding with administering the medication. Although computers were introduced to reduce documentation errors, verification of computer information is safe, effective nursing care. Checking for allergies is a reasonable nursing action; however, if a computer error misidentified the patient, then checking allergies of the wrong person can result in misidentification and serious adverse effects for this older adult. The nurse avoids documenting the medication as given until after the patient takes or receives the medication. The nurse avoids administering the medication until after verifying the patient identity a second time for safety. Further, regulatory agencies can require multiple forms of patient identification.

ANS: C NOC helps the nurse categorize the desired end-result of nursing care with specific, measurable, patient-oriented, and time-sensitive endpoints for the patient to achieve. A nursing diagnosis from NANDA identifies the patient problem and the associated nursing interventions and outcomes for the problem. Nursing goals classification does not exist. NIC is a set of nursing interventions whose basis is found in evidence-based nursing and is associated with a specific nursing diagnosis.

ANS: D Mandated by the federal government to improve the quality of care for nursing home residents, the nurse uses the RAI to help residents in nursing homes achieve optimal functional status. The RAI includes identification of issues with the MDS, a comprehensive assessment from Resident Assessment Protocols (RAPs), and the foundation for reimbursement using the RUG. Narrative progress notes are used in nursing homes to describe events that are unsuitable for other forms of documentation in the medical record. Problem-oriented documentation identifies resident problems, the plan of care to resolve the problem, and the outcome of the problem or response to treatment. The RUG is the reimbursement tool in the RAI.

ANS: C The nurse uses the RAPs to assess triggers identified from the MDS. To help the resident achieve optimal functional status by determining his strengths, needs, and preferences, RAPs provide an organized framework used by the health care team for additional assessment of the trigger. The nurse develops the care plan after completing the RAPs. The nurse assigns suitable nursing interventions to the plan of care. The nurse uses agency-approved policies to provide care as assigned in the plan of care.

ANS: B The nurse must add the vital signs and information about the older adult's health care beliefs to the OASIS. The nurse does not need to add information about the older adult's activity level. The nurse does not need to add information about the older adult's functional status. The nurse does not need to add demographic information about the older adult to the documentation tool.

ANS: C To ensure patient understanding, the nurse explains a patient's rights about information access to the patient with the assistance of an interpreter. The nurse is responsible for patient understanding and thus cannot relinquish this task to another person. When understanding is reached concerning the rights associated with access to information, the patient can then make an informed decision about releasing health care information and thus maintain privacy. The nurse cannot ensure patient understanding without discussing the document with the patient using an interpreter. The nurse cannot delegate a nursing responsibility to a family member; the nurse does not have the right to release the health information to anyone. In private or public, the nurse cannot delegate this task to another person.

ANS: A, B, E, F An institution uses the same nursing documentation record because it helps provide continuity of care across various settings by providing organized, pertinent, and thorough health care data on a specific individual. Other units in the hospital and other health care settings have an easier time locating relevant data. Specific health care data are found in one location on a standardized nursing documentation record throughout an institution and provide the basis for standardized patient evaluation across settings. Standardized documents help describe patient acuity levels and thus provide a justification for staffing. Because the same parameters are, or should be, recorded across all units, the standardized documentation record allows for hospital-wide quality evaluations. Nurses must restrict access to a standardized documentation record or any other type of patient record such as laboratory reports, narrative or progress notes, and other documents. A standardized nursing documentation record can reduce a specific type of documentation error but is unlikely to affect the rate of medication errors.

ANS: A, B, C The OASIS was implemented to provide the format for a comprehensive assessment, which forms the basis for planning care and measuring patient outcomes-based quality improvement (OBQI) (CMS, 2011). As with all other documentation systems, OASIS is used to improve both the quality of care and the communication about the individual and serve as a guide for reimbursement. The OASIS assessment does not evaluate the level of patient disability; however, a portion of the assessment addresses the functional capabilities of the patient to perform activities of daily living.

ANS: B, C, D The Clock Drawing Test, which has been used since 1992, is a screening tool that helps identify those with a cognitive impairment and is used as a measure of severity. The Mini-Cog was developed as a tool that could establish cognitive status more quickly than the MMSE and the limitations of educational adjustments. It is now the recommended evidenced-based tool and combines one aspect of the MMSE (short-term memory recall) with the test of executive function of the Clock Drawing Test. It has been found to be highly sensitive to diagnosing dementia. The MMSE tool has been used most often and is a 30-item instrument that has been used to screen for cognitive difficulties and is one of the tools often used in determining a diagnosis of dementia or delirium. Fulmer SPICES is an overall assessment tool developed in 2007.