Nursing chapter 16 – Flashcards

is the act of recording patient status, or client assessment and care in written or electronic form, or in a combination of the two forms. -creating a record of client assessments and care -the act of making a written record

Oral communication about a patient's status

■ Care, in chronological order, provided by all health-care providers ■ The patient's responses to interventions and treat-ments ■ Important facts about a client's health history, includ-ing past and present illnesses, examinations, tests, treatments, and outcomes

-communication between providers -educational tool -legal documentation of care -quality improvement -research -reimbursement -education

SOURCE ORIENTED members of each discipline record their findings in a separately labeled section of the chart -disciplines charted separately -variety of sections -admission data -advanced directive -history & physical - physicians orders -progress notes -diagnostic studies -laboratory data -nurses notes -graphic data -rehabilitation therapy -discharge planning -data scattered; may led to fragmentation

PROBLEM ORIENTED -organized around the patients problems -four compontets: Database Problem list plan of care progress notes -allows greater collaboration -there are no separate sections for each discipline

is more than a format; -it is a system of charting in only significant findings or exceptions to standards and norms of care are charted. -streamlines charting and saves time -uses preprinted forms and checklists. -inadvertent omissions are the biggest problem. -CBE assumes that unless a separate entry is made (exception) all standards have been met and the patient has responded normally.

Narrative format is used with written source-oriented and problem oriented charts. -The Narrative chart entry tells the story of the patients experience in chronological format. - the goal is to track the client's changing health status and progress toward goals. -can be lengthy and idsorganized

the PIE system organizes information according to the patients problems and requires keeping daily assessment record and progress notes -provides a nursing focused rather than medical-focused. -used only in problem oriented charting -establishes an outgoing plan of care

Subjective data Objective Data Assessment Plan Interventions Evaluation Revision-changes made to original care plan.

the term focus is used to encourage you to view the clients status from a positive perspective rather than the negative focus in problem charting. -Focus Charting uses assessment data to evaluate client concerns, problems, or strengths in 3 columns Column 1: Time & Date Column 2: Focus or problem being addressed Column 3: Charting in DAR format: Data, Action, Response

-Flowsheets-individualize specific services -Assessments-with baseline data -Concise, integrated progress notes and flowsheets. -Timely entries. -fact documentation includes only exceptions to the norm or significant information about the patient.

Record of baseline data from which to monitor change -helps forecast future needs.

A separate nursing admission form or a combined interdisciplinary form is completed at the time the patient enters the health care system. -chief complain, reason for admission -physical assessment data -vital signs -allergy information -current medications -ADL's status and discharge planning information/needs -data about client support system and contact information

-Record routine aspects of care (hygiene, turning) -Document assessments; usually organized according to body systems -checklist some checklist include the nursing interventions. -Track client response to care (wound care, pain, intravenous fluids) -Graphic records - used to record vital signs -Intake and output record

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-Comprehensive list of all ordered medications -Provides information on client's medication allergies -Documents scheduled/routine, PRN, STAT, or omitted doses Additional explanation may be required for nonroutine or omitted medications -injection, you must chart the site of administration. -some medications require assessments before to ensure it is safe to give . if not hold the medicine and notify the prescriber

KARDEX-a speical paper form or folding card that briefly summarizes a patient's status and plan of care. Demographic data Medical diagnoses Allergies Diet/activity orders Safety precautions

Intravenous therapy orders Ordered treatments (wound care, physical therapy), surgery, laboratory, and tests A summary of medications ordered Special instructions such as preferred intensity of care or isolation orders -the paper Kardex and the electronic care summary are not permanent part of the patients health record.

-A combined charting and care plan form -Maps out on a daily basis, from admission to discharge -Client outcomes, interventions, and treatments for a specific diagnosis or condition -Laboratory work, diagnostic testing, medications, and therapies included in the pathway -IPOC help predict length of stay, monitor costs of care, and can assist with staffing. -eliminate duplicate charting,increase team effort, and enhance the nurse's teaching about what the patient can expect during the hospital stay.

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

Formal record of unusual occurrence or accident Not a part of patient's health record Quality improvement -report all errors even if there was no adverse impact on the client.

may be -verbal -thorough walking rounds -audio- recorded report(not preferred)

-Client demographics and diagnoses -Relevant medical history -Significant assessment findings -Treatments (e.g., wound care,breathing treatments) -Upcoming diagnostics or procedures -Restrictions (e.g., diet, activity, isolation) -Plan of care for the client -Concerns

-Use a standardized format such as SBAR (situation-background assessment recommendation) useful for interdisciplinary communication or PACE (Patient/problem, assessment/actions, continuing/changing, and evaluation) -Keep it CUBAN: ~Confidential ~Uninterrupted ~Brief ~Accurate ~Named Nurse -Regardless of the format used you need to collect t he following information -Client progress made during your shift -Therapies and treatments -teaching done -consultations done or planned with other disciplines status of identified desired outcomes -any changes in client status -progress made on discharge planning

Transfer reports are give when a patient is transferred from unit or from facility to facility. -Your contact information -Client demographics, diagnoses, reason for transfer -Family contact information- -Summary of care -Current status, including medications, treatments, and tubes in the client -Presence of wounds or open areas of the skin -Special directives, code status, preferred intensity of care, or isolation required -Always ask if the receiver has any questions

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

Verbal orders Spoken to you; often during a client emergency Should be made for critical change in patient condition Telephone orders Received by phone and transcribed onto chart order sheet Have an increased risk for errors

Write the order only if you heard it yourself Make sure the verbal orders make sense with the client's status Repeat the order to confirm accuracy Spell unfamiliar names; pronounce digits of numbers separately

Directly transcribe the order on the chart Date/time Text To followed by provider's name Your signature Physicians must countersign within 24 hours

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

~home-bound status ~Assessment highlighting changes in the client's condition -Interventions performed (wound care, teaching, etc.) -Client's response to interventions -Any interaction or teaching that you conducted with caregivers -Any interaction with the client's physician -Most common used paper home health documentation form is known as OASIS- the outcome and assessment information set.

Minimum data set (MDS) for resident assessment and care screening must be completed within 4 days of admission and updated every 3 months

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

-Be accurate and nonjudgmental -Adhere to the requirements for reimbursement -Provide details about the client's condition, nursing interventions provided, and client response -Document legibly and as soon as possible

-Record significant events or changes in condition -Record any attempts you have made to contact the primary care provider -Chart teaching performed -Chart use of restraints, including reason for use, type of restraints, and frequent checks of the client

-Do not chart that you have filled out an occurrence report -Chart any client refusal of treatment or medication -Document any spiritual concerns expressed by the client and your interventions

-Always use black or blue ink for handwritten notes -Date, time, and sign all notes -Avoid subjective terms -Use proper spelling and grammar -Use only authorized abbreviations -Document complete data about medications

If a client refuses medication -Record on the medication administration record in narrative form; chart the reason given -Do not leave blank lines -If you make a mistake, draw a single line through the entry and place your initials next to the change -Sign all your charting entries

Identify the purposes of the client health record. Answer: The purposes of the client record are as follows: ● Communication among health professionals and continuity of care ● Legal documentation ● Education of health professionals ● Legislative requirements ● Quality improvement ● To meet professional standards of care ● Identification of the cost of care for reimbursement and utilization review ● Health-related research

What are the key differences in the organization of source-oriented records, problem-oriented records, 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 flowsheets 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

What are three advantages of traditional, paper health records? Answer: ● Familiar documentation model with long history of use in healthcare ● Does not require large databases and secure networks to function ● No need for downtime processes ● Relatively inexpensive to create new forms and update old ones

What are three advantages of electronic health records? Answer: ● Multiple healthcare providers access the same information at same time ● Up to one-quarter reduction in time nurses spend documenting client data ● Information stored and retrieved quickly and easily ● Information accessed remotely to improve care ● Specific protocols programmed into the system based on the condition and problems of the client ● Embedded protocols improve consistency of care and adherence to clinical practice guidelines. ● Medical errors prevented through programmed alerts and clinical reminders that automatically display cautions and warnings when actions are taken that could be harmful ● Repetition and duplication reduced ● Communication improved between healthcare providers ● Queries run and data collected in reports that gather specific information regarding nursing care or client characteristics very quickly ● Information permanently stored and not likely to be lost ● Confidentiality of client information protected by tracking everyone who enters the chart, proper security clearances, unique passwords, and restricted access ● A few EHRs integrate client information between multiple areas of the organization so that one area can see information from another area as it is verified ● Helps organizations more effectively meet regulatory requirements and accreditation goals

Summarize the characteristics, advantages, and disadvantages of each of the different kinds of nursing documentation formats (narrative, PIE, SOAP, Focus®, CBE, FACT, and electronic entry). Answer: The following characteristics should be in your summary: ● Narrative format tells the story of the patient's experience in a chronological format. Patient status, activities, and response to treatment may all be included in narrative charting. ● PIE format is organized according to problem, interventions, and evaluation. Problems are identified at the admission assessment. Subsequent entries begin with identification of the problem number. This type of charting establishes an ongoing care plan. ● SOAP charting is organized according to subjective data, objective data, assessment, and plan. This format may be used to address single problems or to write summative patient notes. ● Focus® charting is not necessarily organized according to problems. It can highlight the client's concerns, problems, or strengths. Charting occurs in three columns. The first column contains the time and date. The second column identifies the focus or problem addressed in the note. The third column contains charting in a DAR format. DAR is an acronym for data, action, and response. ● CBE charting utilizes preprinted flowsheets to document most aspects of care. CBE assumes that unless a separate entry is made—an exception—all standards have been met with a normal response. CBE flowsheets vary by specialty and in some cases even by diagnosis. ● FACT system is similar to CBE in that it includes only exceptions to the norm. It includes four key elements: (1) Flow sheets individualized to specific services, (2) Assessment features standardized with baseline parameters, (3) Concise, integrated progress notes and flowsheets documenting the client's condition and responses, and (4) Timely entries documented when care is given. ● Electronic entry format includes forms, flowsheets, and progress notes and may use a combination of electronic and paper entry. Narrative, SOAP, PIE, POC, Focus®, or FACT formats may be used in the progress notes

dentify 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, flowsheets, 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 Kardexâ 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 (Kardexâ).

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.

What are some reasons for the slow adoption of electronic documentation and EMRs in the United States? Answer: High cost of purchasing, customizing, and maintaining the systems; getting the existing computer applications (e.g., billing) to exchange data with the new applications (e.g., care documentation); resistance from physicians and nurses who are comfortable with paper records and see no reason to chang

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

Identify the following abbreviations: Answer: abd abdomen or abdominal BRP bathroom privileges DM diabetes mellitus fx fracture NKDA no known drug allergies OOB out of bed pc after meals PRN as needed STD sexually transmitted disease tid three times per day q every (note that the abbreviations Q.O.D., QOD, q.o.d., qod, Q.D., QD, q.d., and qd are on the Joint Commission "do not use" list. The letter "q" in other combinations is not on that list. LUQ left upper quadran

ow do home care and long-term care documentation differ from hospital-based documentation? Answer: There 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.

What data should be included in a handoff report? Answer: The following data are key points to include in a change-of-shift report: ● Patient's name, age, and room number ● Patient's admitting diagnosis (one or several may exist) ● Patient's relevant past medical history ● Treatments the patient has received at this admission (e.g., surgery, line placements, breathing treatments) ● Upcoming diagnostics, surgeries, or treatments ● Restrictions on the patient (e.g., diet, bedrest, isolation) ● Plan of care for the patient (e.g., IV therapy, pain management, medications, wound care, patient or family concerns) ● Significant assessment findings from the previous shifts ● What are the types of handoff reports? Answer: The handoff report may be written or oral. Oral report allows interaction. Oral report may be given at the bedside or in a conference room and may be audio recorded

What important factors should you document when receiving a telephone prescription? 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 have 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

What is the purpose of a verbal order? When should it be used? Answer: Verbal orders are spoken prescriptions given to you in person. Often these occur in an emergency situation. Never use verbal orders as a routine method of communicating prescriptions. Follow the same guidelines as you would use for telephone orders.

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 concern

When should care be documented? Answer: Documentation should be performed as soon as possible after you make an observation or provid

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.

Can charting be delegated? Answer: Each member of the team is responsible for documenting her part in the care of the patient. Nursing assistants often chart activities of daily living (ADLs), activity level, and intake and output on graphic records. You are responsible for documenting the care you provide. Never chart the actions of others as if you performed them. If an action is crucial to a chain of events, you may document that action if you observed

u are a student nurse on a medical-surgical unit. You review your patient's chart and notice that the physician has entered prescriptions that do not appear to be appropriate for your patient. 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.