Nursing Fundamentals Chapter 3 Documentation – Flashcards
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What is a chart?
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legal records that is used to meet the many dreams of the health, accreditation, medical insurance, and legal systems
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When charting interventions, what is essential?
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type of intervention, time care was rendered, signature an tile to person providing care
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Why is documentation an integral part of the implementation phase?
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necessary for evaluation of patient care and for reimbursement for the cost of care provided
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What are requirements for licensure and employment as a nurse?
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knowledge of basic guilds, and the ability to chart completely, accurately, and legible
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What are the five basic purpose for accurate and complete patient records?
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documented communication, permanent record for accountability, legal record of care, teaching, research and data collection
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auditors
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people appointed to examine patient charts and health records to assess quality of care
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peer review systems
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an appraisal by professional coworkers of equal status
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What are the only means an institutions have to prove that they are providing care to meet patient needs ad established standards?
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accurate and legible records
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What are nursing notes?
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form on the patient's chart on which nurses record their observations, the care given, and the patients response
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What do EHR's do?
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eliminate repetitive entries and allow more freedom of access to the database; increase efficiency consistency, accuracy, and decrease costs
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What does SBAR mean?
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situation, background, assessment, and recommendation
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When and why is SBAR used?
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to safely measure prevention of errors from poor communication during handover from shift to shift
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What is recognized by the Joint Commission as one method of meeting National Patient safety Goals?
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SBAR
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What has a decisive impart on the success or failure of communication?
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quality and accuracy of nursing notes
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What skills are critical when using non-computer based systems?
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correct choice of words and spelling, grammar, punctuation, in addition to good penmanship and other writing skills, fill all spaces/leave no empty line
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Who has the primary responsibility for patient's initial admission nursing history, physical assessment, and development of the care plan based on the nursing diagnoses identified?
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Registered Nurse
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What are the basis rules to include charting?
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correct patient, name, id number, date and time, approved medical terms only, be timely specific, accurate and complete,
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When should you be charting?
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after the care is provided, and as soon and as often as necessary
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What should you do if you question a doctor's orders?
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record the clarification was sought
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What is one of the best defense in the event of legal claims associated with nursing care?
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accurate documentation
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During documentation, who is responsible to indicate all assessments, interventions, patient responses, instructions,, and referrals in the medical record?
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the nurse
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What are some examples of inappropriate documentation?
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not charting the correct time that events occurred or that an event occurred at all, failing to record verbal orders, charting nursing care in advance, documenting incorrect data
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What are the typical sections in traditional block chart?
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admission information, physicians orders, progress notes, history and physical examination data, nurse's admission information, care plan and nursing note, graphics, lab/xray reports
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What does narrative charting include?
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data (subjective/objective/both) about basic patient need, whether anyone has been contacted, care and treatments provided, and patient's response to treatments
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problem-oriented medical record
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organized according to the scientific problem-solving systems
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What are the principal sections in a problem-orientated medical record?
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database, problem list, care plan, and progress notes
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What is the acronym for seven different aspect of charting?
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SOAPIER
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Subjective
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what patient states or feels; only patient can provide this information
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Objective
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what nurse can measure or factually describe
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Assessment
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an analysis or potential diagnosis of the cause of patients problem or need
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Plan
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general statement of the plan of care to be given or action to be taken
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Intervention
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specific care give or action taken
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Evaluation
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appraisal of response and effectiveness of the plan
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Revision
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changes that may be made to the original plan of care
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What is it called when a modified list of nursing diagnoses are used as an index for nursing documentation instead of problem lists?
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focus charting format
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What is the focus of focus charting format?
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patient concern/behavior, significant change is patient status
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What is the acronym for four different aspects of charting using the focus format?
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Dare; Data, action, response and evaluation, education and patient teaching
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Nursing care plan
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plan that outlines the proposed nursing care based on the nursing assessment and nursing diagnoses to provide continuity of care
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Why was the nursing care plan developed?
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to meet the nursing care needs of a patient
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What do standard nursing care plans include?
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pertinent nursing diagnoses, goals, and plans for care and specific actions for care implementation and evaluation
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Incident report
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form used to document any event not consistent with the routine operation of a health care unit or the routine care of patient
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What is one of the benefits in tracking particular incidents?
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prevention of future problems through education and other corrective measures
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What should be included in an incident report?
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objectivie, observed information, not admit liability or give unnecessary details, care given to patient in response and name of health care provider contacted
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Acuity charting
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uses a score that rates each patient by severity of illness
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What is good about a 24 hour record keeping system?
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eliminates unnecessary record keeping forms, easier to obtain accurate assessment information and documentation of activities of daily living with 24 hour notation
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When does discharge planning occur?
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beings at admission and in some cases before admission
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What does a discharge summary do?
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provides important information that pertains to the patient's continue health care after discharge
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Clinical pathways
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allow staff from all disciplines to develop standardized, integrated care plans for projected length of stay for patients of specific case type
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What are the contents of a clinical pathway?
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care plan, interventions specific for each day of hospitalization and documentation tool
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CBE
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chart by exception
