question

Why is proper nursing documentation important?

answer

Because it creates a legal record of all patient interactions, it promotes effective communication, and provides a record of the quality of care provided to the patient.

question

Define Documentation

answer

The written or typed legal record of all pertinent interactions with the patient

question

What is the purpose of creating patient records?

answer

1. Communication (between disciplines, ie doctors, other nurses, PT, OT etc) 2. Maintain diagnostic and therapeutic orders 3. Care planning 4. Quality review to ensure standards of care being followed 5. Research 6. Education 7. Legal documentation 8. Reimbursement 9. Provide a record of the medical Hx

question

Define how proper documentation should appear in the record

answer

The content in the record should be complete, accurate, concise, current and factual

question

What information should be included in the patients chart?

answer

Document what you see, hear, feel, smell, measure, and count

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What information should not be documented in the patients chart?

answer

Do not document what you suppose, infer, conclude, or assume.

question

Name three words that should not be used when charting

answer

1. good 2. average 3. normal

question

What should be included in a patient's chart to ensure accuracy?

answer

1. Exact descriptions 2. Nursing interventions and the patients response 3. Charting of decimal points correctly 4. Charting correct information, use the patients own words when possible 5. Do not stereotype or use derogatory terms

question

When assessing or visiting a patient, what should be charted?

answer

Document all interactions; including medical visits and consultations

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When communicating with the provider, what information should be documented?

answer

The date, time, reason and response to any communication with the provider

question

When would you chart information for another nurse?

answer

Never; you should never document for anyone else

question

When recording time, should you use AM and PM or military time?

answer

Military time

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When do you chart medications?

answer

After they are given; if medications are not given document the reason why

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Can you chart nursing care or observations in advance?

answer

No, never document care or observations in advance. When you do perform nursing care and observe the patient always document the date and time of each entry.

question

When do you chart patient interactions, assessments observations, medications etc.?

answer

Chart all of this information immediately when possible (exception: when precautions are in place) then document ASAP. Do not wait until the end of the shift to chart!

question

Why do you not wait until the end of the shift to chart?

answer

Recalled information can be incorrect, confused, omitted etc.; resulting in documentation errors.

question

What aspects are considered important when documenting?

answer

1. Verify the chart you are using is correct!! 2. Use the same format 3. Use proper grammar and spelling 4. Use standard terminology 5. Use only approved abbreviations 6. Written: use only hospital approved forms and black in only 7. Do not leave blank spaces; fill them in with a line or large X

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What is the purpose of nursing assessment documentation?

answer

To record the status/condition of a patient at a specific date and time.

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What is the purpose of documenting the nursing care plan?

answer

Generally these plans of care include nursing diagnoses, expected outcomes, and interventions.

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What is the purpose of nursing documentation in relation to progress notes?

answer

It allows for the documentation for the progress/status of the patient during the shift. Also provides a way to report care during the change of shift.

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What is the purpose of nursing documentation in relation to flow sheets?

answer

To provide a graphic record of weight, VS, I&O. Also contains the MAR and wound assessment information Flow sheets help team members quickly see patient trends over time and decrease time spent on writing narrative notes

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What is the purpose of nursing documentation in relation to medication administration?

answer

Medication administration should be documented only after the medication is given; if the medication is not give the reason should be documented.

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What is the purpose of nursing documentation in relation to administration records?

answer

The patient record is a valuable source of data for all members of the health care team. Its purposes include communication, legal documentation, financial billing, education, research, and auditing/monitoring.

question

Describe the method for documenting nursing interventions

answer

Should be documented in conjunction with current condition and response/evaluation of treatment. Allows for the creation of individual care plans for patients.

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What is one key factor that ties to the reason all information is documented completely and accurately?

answer

Accountability of the nurse to the care of the patient.

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In written documentation, what should be included on each page?

answer

Include the client's name and ID on each page; sign and title each entry and place a full signature when required

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When a full signature is not required in written documentation, how can it be recorded?

answer

First initial, last name, title

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How is an addendum attached in written documentation?

answer

Addendum are not written in the margins; they are entered with a date time with "late entry" if needed.

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What are the 3 key points to remember when recording written documentation?

answer

1. They should be neat, legible and use proper spelling and language 2. Do not cover with tape or obliterate information 3. Do not use any form of correction fluid; correct according to hospital policy (single line, initial, time, date and reason)

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How should telephone orders be taken from the physician?

answer

1. Always repeat to verify accuracy 2. Must be cosigned within agency time frame 3. The order should be recorded on the pt. chart, include the date and time, T.O., full name and title of physician, sign with the nurses name and title.

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When is the use of verbal orders acceptable?

answer

In emergency situations only; must be signed by the MD or NP after the emergency

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What methods are used to document progress notes?

answer

PIE, SOAP and DAR

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What are the 4 types of reports given by nurses?

answer

1. Change of shift 2. Telephone/telemedicine reports 3. Transfer and discharge reports 4. Given to Family members/ significant others

question

What are the 3 types of change of shift reports?

answer

1. Written 2. Face to face 3. Bedside rounds

question

What is ISBARR

answer

Identify (self, patient) Situation (you are calling about) Background (diagnosis, date of admission, VS, mental status, IV, lab results) Assessment (what you think is going on) Recommendation (what you need from the physician) Read back

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Who do nurses confer with about care

answer

Specialists (for consultations), referrals (PT, OT, hospice, home health, social services)

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What is an incident report?

answer

A record of an accident or an unusual occurrence, they identify risks, not used for disciplinary action, not part of the patient record

question

When are incident reports filled out?

answer

When a patient falls, a visitor falls or due to a medication error.

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What are the advantages of computerized records?

answer

Convenient, multiple specialties have access to it, can view it from office vs hospital, legible

question

What are the disadvantages of computerized records?

answer

Can be seen by anyone, crashing computers

question

What is the most important part of nursing documentation to consider?

answer

If it was not documented, it was never done.

question

Define SOAP

answer

Subjective, Objective, Assessment, Plan; frequently used to document progress notes, has an origin in medical records

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Define SOAPIE

answer

Subjective, Objective, Assessment, Plan, Intervention and Evaluation

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Define PIE

answer

Problem, Intervention, Evaluation; a form of documenting progress notes, a narrative note, has an origin in nursing

question

Define DAR

answer

Data, action, response; a form of focus charting

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