Documentation – Flashcards
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Shift change report
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Purpose of _____. **To ensure Continuity or Care** Discuss progress towards goals, problem solve. Provides vital information to the oncoming nurse to plan and prioritize care.
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Characteristics of reporting
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_________ to another Healthcare Professional. Follows specific sequence. Contains basic identification information (Name, Bed, and Room). Gives reasons for admission, medical dx, date of surgery, and diagnostic test. Identifies significant changes in condition and current plan to address change. Provides concise details.
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Relevant issues
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Include other ______. Relevant psychosocial data. Information about admissions, discharges, transfers. Priorities of care: IV bag changes due w/in next hr; pain meds that becomes due at shift; change outstanding calls to MD, unresolved problems related to client condition, need for f/u care).
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Good Healthcare records
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Characteristics of __________. Meet legal, ANA, TJC, and other accreditation standards. Include date and time for all records. Timing: Document as you go through your shift. Legible and easy to read (blue/black ink only). Spelling. Signature (in order for it to become a legal document).
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Healthcare records
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Purpose of _______. Communication. Planning client care. Auditing. Research. Education. Reimbursement. Legal documentation. Record can be subpoenaed. Health care analysis.
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Do's
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Practice guidelines _____. Chart changes in clients condition. Timely. Read previous nurses notes. Use factual information. Correct all errors. Chart all teaching. Chart actual clients words in "quotes." Chart all client responses to interventions. Review all notes (make sure they are clear and reflect pt condition). If an order was questioned, record that clarification was sought.
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Dont's
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Practice guidelines _______. Leave blank space, chart in advance, use vague terms, chart for someone else, use white out or alter client records, and use bias or perceptions incharting.
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Legal guidelines
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Follow these principles. Strive for Accuracy. Remember: You chart reflects your integrity. Learn to respect the Privacy rights outlined by HIPPA.
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Confidentiality of records
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Written communication: Accessible only to those who need to know. Names not visible to visitors. Keep computer information confidential: Log off before you leave. Guard password in work area. Control what the public cant see. Shred documents after use. Follow facility protocol for correction of errors.
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Confidentiality of records
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Verbal communication: Walking rounds. Student guidelines: Be care of where you are keeping your information
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Computers in nursing
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Computerized charting, access to laboratory values. Access to databases such as treatment plans, pharmacology information, patient teaching information, access to treatment received at remote locations.
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Documentation systems
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Source oriented record (SOR), Problem oriented medical record (POMR), Problems interventions evaluations (PIE), Focus charting, Charting by exception (CBE), Computerized documentation, Case management.
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Problem oriented medical records (POMR)
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Documentation method that permits analytical focus on identified client problems. Chart divided as follows: Database, problem list, plan of case, and progress notes.
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Problem oriented medical records (POMR)
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Advantages: Team collaborates to create plan. Provides quick identification of recognized problems. Disadvantages: Charting may be lengthy, redundant. Problem list may not be kept up to date.
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SOAP format
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S: Subjective: What the client says, in quotes. O: Objective: What you observed or measured. A: Assessment: interpretation, conclusion, diagnosis, problem OR progress towards goals. P: Plan: What will be done about the problem. I: Intervention: Actions taken during shift. E: Evaluation: How did the client respond to intervention? R: Revision: Changes made to care plan.
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SOAP Example
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It's "hard to take a deep breath." Client sitting upright in bed. RR 28. O2 sat 90% on RA. Wheezing bilateral all in all lung fields on auscultation. Ineffective breathing pattern. Notify physician, provide comfort. Administer O2 at 3L/M, Albuteral neb tx as ordered. Pt more comfortable, O2 sat 96% on O2, decreased wheezing bil after resp tx.
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SOAP and Nursing process
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S: Subjective & O: Objective=Data collection while assessing the client.; A: Assessment; Nursing diagnosis; P: Plan; Planning. I: Intervention; Implementation. E: Evaluating; Evaluation.
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APIE Format
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Assessment (includes subjective and objective data in support of Assessment), Planning (Problem), Intervention, and Evaluation.
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APIE and nursing process
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Assessment=Data collection/nursing Dx. Planning=Planning. Intervention (What's going on)=Implementation (What you did; SN did this/that). Evaluation=Evaluation.
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APIE Example
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A: Ineffective breathing pattern P: Notify physician, provide comfort I: Administer O2 at 3L/M, Albuterol neb tx as ordered. E: Pt more comfortable, O2 sat 96% on O2, decreased wheezing bil after resp tx.
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Focus charting
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A condition (hypoglycemia). Nursing diagnosis (skin integrity, pain, etc.). Behavior (yelling and belligerent). S/Sx (nausea/vomiting). Acute change in client's condition (low BP).
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DAR(P) and nursing process
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Data=subjective/objective. Action=planning/implementation. Response=Evaluation. Plan=Revisions/Change in Plan.
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Example DARP charting
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Data: Temp, oral-101.0 F, skin hot, dry, pt c/o "aching all over." Action: Call to MD, order given for Tylenol one gram po now. Response: Recheck one hr after Tylenol given, Temp now 99.8 orally. Plan: Continue with q 4 hr vital signs.
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Charting by exception (CBE)
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A documentation system in which only significant findings or deviations from norms are recorded. Three important components: Flow sheets, standards of care, and bedside access to chart.
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CBE Advantages
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Elimination of lengthy repetitive notes, Flow sheets for specific entities, reports changes in clients condition, easier to read and pick out problem areas.
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CBE Disadvantages
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Some nurses feel uncomfortable with _________. Must fill in all blanks with N/A- no blank spaces. Must know normal standards of care for healthcare organization (minimum criteria).
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Forms with specific focus
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Skin assessment form, Pain management flow sheet, incident report, and critical pathways (case management).
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Case management
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______ related to Critical Pathways. Length of stay-predetermined. Ex: CHF, Pneumonia. Based on Medical Dx. Interventions. Outcomes. **Goals not met are called-Variances**
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Critical Pathways
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Criteria for length of stay. Criteria for expected outcome. Criteria for specific interventions. Documentation of client;s progress and/or variance towards goals or outcomes.
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Quality professional
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The road to _______ communications. Learn how to accurately describe what you observe. Use Nursing Process to ensure that problems addressed systematically. Follow agency guidelines.
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Improve and Enhance
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_______ documentation. Read documentation. Use rating scales, abbreviations approved by institution. Keep up with medication error prevention issues related to charting. Audit you own charts!
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Psychosocial
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_______ History Admission Assessment. Support system (married). Level of anxiety (Mild, moderate, or severe). Calm or anxious (Behavior, depressed). Recent stressors (Divorced, separated).
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Neurological
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_______ History Admission Assessment. LOC- Level of Consciousness- Awake, alert, drowsy, semiconscious, or unconscious.
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Neurological
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Documentation examples. Orientation: Person, place, time, situation (A/Ox3). Pupils: PERRLA. Extremity strength: ROM, equal strength (squeeze hand, push against resistance). Speech: Clear, gargled, slurred, inappropriate language. Facial symmetry: equal.
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Mobility ROM
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Examples. Weakness: Upper/lower extremity R<L. Paralysis: Flaccid R U Extr, rigid LL Extr. Contractures: Contractures bilat lower extr. Joint swelling: Lt knee joint pain swelling noted. Pain: Pain on ROM of LUE radiation, dull-sharp, throbbing.
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Aeration-Respiratory
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Examples: Pattern: RR, shallow, deep, tachypenic apnec (w/o). Breading sounds: Rales, rhonchi, wheezing not bilat lower lobes. Cough: + dry/secretions. Secretions: yellow. Pulses: weak, thready, bounding. Edema: where, edema 3+ noted in bilt ankles. Perfusion: gas exchange, O2 stats, cap refill <3.
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Gastrointestinal
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_________-Nutrition/fluids. Examples: Oral mucosa (Pink, moist MM, intact). Appetite (Ate 20% of meal). Bowel sounds (BS present in all 4 quad). Abd tenderness (Non tender to palpate). Presence of N/V (No N/V). Last BM (9/30/12 x2). Stool frequency (Everyday).
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Elimination
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________-Genitourinary. Examples: Last voided (2 hrs ago). Urine color (clear, yellow). Presence of incontinence (incontinence during the night). Catheter (foley draining, hematuria). Vaginal/Penile discharge (No vaginal/discharge). Urinary complaints- dysuria/frequency.
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Integumentary
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________-Fluids. Examples: Temperature (warm, cold). Color (consistant with ethnic group). Moisture (dry, moist). Turgor. Edema.
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Wounds/scars
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Examples: Type- Decubitus ulcer, surgical wound, suture line. Staging- Laceration, rash, GSW (stage 3 decub). Drainage- Purulent, serous, serosanguineous. Dressings- Dry/intact. Sutures- Clean&Dry.
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Narrative Note
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Normal assessment example. Neuro- Client A/O x3, calm, resting in bed, PERRLA, MAE x4. Resp- Chest CTA bilat on auscult. RR reg.
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Narrative Note
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Normal assessment example. CV- S1, S2 on auscult, reg rhythm, palp pulses all 4 extr, vs stable. GI- Abd soft, non-tender to palp, BS + all 4 quads, ate 50% of meal, denies n/v.
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Narrative Note
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Normal assessment example. GU- Voiding clear, yellow urine, denies dysuria, Mobility- gait steady, ambulates well w/o assist, denies pain. Skin- w/d, pink, cap refill <3 sec.
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Narrative Note
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Abnormal assessment example. Neuro- Client awake, disoriented to time and place, slurred speech, facial dropping on right, grasps R>L, pupils unequal L>R, see neuro assessment sheet. Resp- Chest rales noted bilat on auscult in LL. O2 sat 93% on RA.
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Narrative Note
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Abnormal assessment example. CV- S1, S2, Gill sys murmur noted on auscult, irregular rhythm. GI- Abd firm, tender to palp in RUQ, BS diminished in all 4 quads, c/o nausea. GU- foley cath draining hematuria with clots.
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Narrative Note
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Abnormal assessment example. Mobility- client is bedridden with lower extr contractures at knees, with 3+ pitting edema bilat ankles, c/o pain 6/10 on pain scale. Skin- w/d with stage 3 decubitus ulcer posterior coccyx area, see wound assessment sheet. Redness and edema noted to IV site.
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Describe locations
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Proximal/distal, quadrants, anterior/posterior, bilateral/unilateral, symmetry/asymmetry, upper/outer/inner, lateral/medial.
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Descriptive documentation
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Use color spectrum- sputum, urine, stool or other body fluids. Describe appearances- Flat, round, hard, soft, raised, rash, productive, protruding. Use of apporopriate medical terminology- Trach, ventilator, stoma, colostomy, ureterostomy.
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Document
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_____ what you see! BLE pale 3+ pitting edema from toes to mid ant/post tibia area. Erythema noted to posterior bilat heels, L 2x3 cm round, R 3x5 cm round.
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Safety
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Checklist, Risk for, Equipment used, and Environmental issues.
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Documentation checklist
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Examples- Admission assessment, Assessment every shift by RN, Braden scale-Skin assessment, Pain assessment sheet, PCA Flowsheet, Care Plan Documentation, Mobility Assessment, Critical Pathway Sheet, and Medication Administration Sheet.
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Narrative
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Procedure note:______. 10/2/2012 0900 Bowel sounds present all 4 quadrants, + placement of NG by auscult, 20 mL residual on aspiration, returned, 500 mL ensure given bolus via NG, pt tol. well, HOB elevated x 30 minutes-----JM, SFC. 30 minutes later. 10/2/2012 0920 Pt states comfortable, no n/v, turned L side.------JM, SFC.
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SOAP Format
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Procedure note:________. "I feel like I need to vomit." Abd distended, hypoactive BS heard on auscult. Nausea. Report S/S to MD, Order for NGT I: #18 Fr NGT placed R nare, placement checked. Immediate asp 500 mL of greenish/brown drainage via sx, pt tol procedure well, states more comfortable, cont low int sx as ordered.
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APIE Format
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Procedure note: _______. A: Client c/o of nausea, abd distended, hypoactive BS heard on auscult in all 4 quads P: Report s/s to MD, order for NGT I: #18 Fr NGT placed R nare, placement checked E: Immediate asp 500 mL of greenish/brown drainage via sx, pt tol procedure well, states more comfortable, cont low int sx as ordered.
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Narrative
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Procedure note:________. #16 Foley cath placed using sterile technique, inflated with 15 mL water draining cl yellow urine, client tol procedure well. U/A sent to lab.-----JM.
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PIE Format
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Fluid Volume Deficit. Adm IV NS 0.9% at 100mL/h as ordered via PIV. VS stable, no n/v, IV patent, IVF infusing @ 100 mL/h, continue to assess for s/s of fluid loss.
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Remember the NP
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_____ In Action. What have you assessed? Assessment. What is your nursing dx? Diagnosis. What is your plan? Plan. Determine your interventions? Implementation. Was my plan and interventions appropriate? Evaluation. (Need for revisions and/or modifications to above).
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Document
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______ WHAT YOU...see, smell, hear, or touch. Not charted=not done!
