Fundamentals Chapter 18 - Documentation Flashcards

the act of recording patient status and care in written or electronic form, or in a combination of the 2 forms.

• Care, in chronological order, provided by all healthcare providers
• The patient’s responses to interventions and treatments
• Important facts about a client’s health history, including past and present illnesses, examinations, tests, treatments, and outcomes

• Communication between providers: Communication between multidisciplinary team members promotes continuity of care.
• Educational tool: The record provides a snapshot of what is going on with the client so you are able to research unfamiliar diagnoses, orders, and treatments before direct care begins.
• Legal documentation of care: Expert reviewers look for documentation of the client’s baseline status, changes in status, interpretation of the changes, interventions implemented, and the client’s responses to those interventions.
• Quality improvement: Results are used to formulate strategies to improve care, decrease length of stay, control costs, and pinpoint knowledge and practice gaps that can be addressed through continuing professional education and in-service education. Accrediting agencies, such as The Joint Commission, review written and electronic records to ensure delivery of quality care and public safety.
• Research: The health record is also used to gather data for clinical research.
• Reimbursement: Insurance companies, government and third-party payers, budget managers, and organization billing staff use client health records to determine the cost of care.

Standardized nursing terminology helps to make nursing care and its effects on patients more visible.

Several standardized nursing language models are used in nursing documentation, such as:

NANDA International (NANDA-I)
Nursing Interventions Classification (NIC)
Nursing Outcomes Classification (NOC)

This system is used in hospitals and long term care facilities because patients receive care from a variety of disciplines. Members of each discipline record their findings in a separately labeled section of the chart. It contains a variety of sections.

The advantage of this system is that you can easily find the care provided by each discipline and the results of lab/diagnostic tests.

The disadvantage of this system is that it may be fragmented and scattered throughout the patient's record. You need to review all sections of the chart to fully understand the patient's condition and care. It is especially difficult with this system to track the treatments and client outcomes associated with a particular problem.

This type of documentation system is organized around the patient's problems. There are no separate sections for each discipline.

It has four components:
database (consists of demographic data)
problem list
plan of care (includes PCP's orders and nsg care plan)
progress notes (organized according to problem list)

The advantages of this system are:

• there is a common problem list that includes input from all disciplines.
• it is easy to monitor the patient’s progress because each problem is readily identified in the notes.
• each discipline has ready access to the findings of the other members of the health team. This may encourage greater collaboration.

The disadvantage of this system is that it requires a cooperative spirit among health providers as well as diligence in maintaining a current database and problem list.

A type of charting that can be used with source or problem oriented systems. It tells the "Story" of the care in chronological format. It tracks the client's changing status.

The disadvantages to this charting type are that it may be time consuming, disorganized, contain multiple and sometimes duplicate entries, requires you to read the entire note or multiple notes to find patient's responses and outcomes to interventions, and doesn't readily id problems and trends.

A type of charting that organizes information according to the patient's problems and requires keeping a daily assessment record and progress notes. Used only in problem oriented documentation. It establishes an ongoing plan of care.

The primary disadvantage of this type of charting is that it does not document the planning portion of the nursing process. There is no seamless flow of client data, nursing diagnosis, and interventions, such as seen in a nursing care plan.

A type of charting that can be used in source oriented, problem oriented, and electronic health records.

• Subjective data: What the patient or family members tell you about the client’s signs and symptoms and the reason they are seeking healthcare. Typically this is documented by quoting the actual words said.
• Objective data: Factual, measurable clinical findings such as vital signs, test results, and quality of breath sounds.
• Assessment: Conclusions drawn from the subjective and objective data, usually patient problems or nursing diagnoses.
• Plan: Short-term and long-term goals and strategies that will be used to relieve the patient’s problems.
• Intervention: Actions of the healthcare team that are performed to achieve expected outcomes.
• Evaluation: An analysis of the effectiveness of interventions.
• Revision: Changes made to the original care plan.

A type of charting that highlights the client's concerns, problems, or strengths in 3 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.

• Data: Subjective and objective information that supports the focus. This aspect reflects the assessment phase of the nursing process and includes other data, such as laboratory results or other diagnostic testing.
• Action: Describes interventions performed, such as administering medications or making calls to the physician. This aspect reflects the planning and implementation phases of the nursing process.
• Response: Describes the patient’s response to your interventions. This aspect reflects the evaluation phase of the nursing process.

A system of charting in which only significant findings or exceptions to standards and norms of care are charted. Is uses pre-printed forms and checklists. This system is used to streamline charting and to save time, but to use this system effectively, you must know and adhere to professional, legal, and organizational guidelines for nursing assessments and interventions.

Inadvertent omissions are the main problem associated with this type of charting. This type of charting can also lead to errors because nurses may conclude that care has been completed, when it has not been done.

A type of charting that includes only exceptions to the norm or significant information about the patient. It eliminates the need to chart normal findings.

FLOW SHEETS individualize specific services

ASSESSMENT with baseline data

CONCISE progress notes

TIMELY entries

Inadvertent omissions are the main problem associated with this type of charting.

A documentation form that creates a baseline assessment and is essential because it (1) may be used as a benchmark to monitor change; (2) provides information about the client’s support system and helps forecast future needs; (3) contains critical information such as presenting illness or reason for admission, vital signs, allergy information, current medications, ADL status, physical assessment data, and discharge planning information.

A documentation form that allows you to see patterns of change in patient status. It can be used to record intake and output (I&O), weight, hygiene measures, ADLs, turning, vitals, and medications administered.

A documentation form that you will document medications according to the times they are given: scheduled, unscheduled, continuous, prn , stat, and so on .

• Drug allergies are always noted on the MAR, whether paper or electronic.
• Patient Refusal. If the patient refuses a medication, note the refusal on the paper or electronic MAR.
• Omitted Medication or Delayed Administration: If the patient is not available or is experiencing health changes that require immediate interventions, it may be necessary to withhold a medication or delay its administration.

*You will also have to document the omission or delay in your nurses’ notes. However, in the electronic MAR, often it is possible to reschedule administration times for a single dose or permanently going forward, or to document that a medication could not be given at the scheduled time and will be skipped.

A special kind of documentation paper form or folding card that briefly summarizes a patient's status and plan of care. May include this information: demographic data, med diagnoses, allergies, diet/activity orders, safety precautions, IV therapy orders, ordered treatments, summary of meds ordered, and special instructions

IS NOT A PERMANENT PART OF THE PATIENT'S HEALTH RECORD.

A documentation form (combined charting and care plan form) that maps out, day by day, the patient goals, outcomes, interventions, and treatments for a specific diagnosis or condition from admission to discharge. Lab work, diagnostic testing, medications, and therapies are all included as well as standardized interventions captured in the plan. It helps administrators predict length of stay, monitor costs of care, and can assist with staffing.

• Other advantages: They eliminate duplicate charting, increase team effort, and enhance the nurse’s teaching about what the patient can expect during the hospital stay.

A documentation form that is aka an incident report. It is a formal record of an unusual occurrence or accident. Include the following info:

• Briefly describe the incident in objective terms.
• Quote the client or persons involved if possible.
• Avoid drawing conclusions or placing blame.
• Identify any witnesses to the event and any equipment involved.

This is NOT a part of the patient's health record and should never be referenced in the nurse's notes or other sections of the health record.

• Patient fall or other injury
• Med error
• Incorrect implementation of a prescribed treatment
• Needlestick injury or other staff injury
• Loss of patient belongings
• injury of a visitor
• Unsafe staffing situations
• Lack of availability of essential patient care supplies
• inadequate response to emergency situation

A communication pathway from one nurse to the next or from a nurse to physician. Allows nurses to prioritize the client’s vital information.

The purpose of this report is to alert the next caregiver about the client’s status or recent changes in the client’s condition and to discuss planned activities, tests, procedures, or concerns that require follow-up.

May be given verbally at the bedside or in a conference room using paper notes or a mobile or desktop EHR device.

SBAR
Situation
Background
Assessment
Recommendation

PACE
Patient/Problem
Assessment/Actions
Continuing/Changes
Evaluation

CUBAN
Confidential
Uninterrupted
Brief
Accurate
Named nurse

• 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—when the next medication is due
• 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.

The last entry made in the paper chart. In the electronic chart, it can be started any time after admission. It will include the following info:

• Time of departure and method of transportation
• Name/relationship of person accompanying pt
• Patient's condition at discharge
• Teaching conducted and handouts given to pt
• All discharge instructions including meds, treatments or activity
• Follow up appointments or referrals given

Spoken directions for patient care given to you in person, usually during an emergency.

When recording this order include the date, time, and the written text of the order or the electronic entry of the order.

If you are writing the order on an order sheet, an indicator “V.O.” designating verbal orders is then followed by the provider’s name and
your name.

An order received by phone and transcribed onto the provider order sheet and has an increased risk for errors. Include the date/time, text, provider's name followed by your signature.

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

If you feel uncertain about an order, you must question it. You may question an illegibly written order, or if you are uncomfortable following an order - follow the chain of command.

• Document immediately: Document as soon as possible after making an observation or providing care. The longer you wait, the less you
  will recall.
• Chart chronologically to communicate the changing status of the patient: If you forget to make an important entry while charting, you will need to add to or modify your documentation. Record the time and date you are charting, but clearly designate this is a late entry.
• Date and time all your documentation.

The Centers for Medicare and Medicaid Services guidelines govern home healthcare documentation. Among the requirements for care are:

• certification of home bound status
• a plan of care
• ongoing assessment of the need for skilled care

The most commonly used paper home health documentation form is know as OASIS - the Outcome and Assessment Information Set.

• Legal requirements to protect older adults mandate that you report changes in a client’s condition to the primary care provider as well as the client’s family.
• Document your reports in narrative notes on paper or in the appropriate areas of electronic forms.
• If you are caring for a client receiving Medicare-reimbursed services, such as IV therapy, wound care, or rehabilitation services, documentation is required with each shift.
• In addition, a summary written by a nurse must be recorded weekly.

Federal law requires that a resident be evaluated using the MDS for Resident Assessment and Care Screening within 14 days of admission. It must be updated every 3 months with any significant change in pt condition.

• 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)

1. nonjudgemental
2. reimbursement
3. patient response
4. asap

1. condition
2. primary care provider
3. teaching
4. restratints

1. DON'T
2. medication
3. spiritual

1. black or blue
2. sign
3. subjective
4. spelling
5. abbreviations
6. medications

1. refuses
2. DON'T
3. draw a single line through the entry and place your initials next to the change
4. sign
5. whiteout

Answer:

2) Patient's dentures lost after transfer

Rationale:

You would need to complete an occurrence report if you suspect your patient's personal items to be lost or stolen. A medication can be administered within a half hour of the administration time without an error in administration; therefore, an occurrence report is not necessary. The worn electrical cord should be taken out of use and reported to the biomedical department. The nurse should seek clarification if the provider's order is missing information; an occurrence report is not necessary.

Answer:

1) separates the health record according to discipline

Rationale:

In source-oriented charting, each discipline documents findings in a separately labeled section of the chart. Problem-oriented charting organizes notes around the patient's problems. Focus^® charting highlights the patient's concerns, problems, and strengths. Charting by exception is a unique charting system designed to streamline documentation.

Answer:

3) NKA

Rationale:

The nurse can use the medical abbreviation NKA, which means no known allergies, to document this finding. NA is an abbreviation for not applicable. NDA is an abbreviation for no (known) drug allergies. NPO is an abbreviation that means nothing by mouth.

Answer:

1) are comprehensive charting forms that integrate assessments and nursing actions

Rationale:

Nursing assessment flowsheets are organized by body systems. The nurse checks the box corresponding to the current assessment findings. Nursing actions, such as wound care, treatments, or IV fluid administration, are also included. Graphic information, such as vital signs, I&O, and routine care, may be found on the graphic record. The admission form contains baseline information

Answer:

4) Make a late entry as an addition to the narrative notes.

Rationale:

If the nurse fails to make an important entry while charting, she should make a late entry as an addition to the narrative notes. An occurrence report is not necessary in this case. If documentation is omitted, there is no legal verification that the procedure was performed. It is illegal to add to a chart entry that was previously documented. The nurse can only document care directly performed or observed. Therefore, the nurse on the incoming shift would not record the wound change as performed

Answer:

3) It improves interdisciplinary collaboration that improves efficiency in procedures.

Rationale:

The EHR has several benefits for use, including improving interdisciplinary collaboration and making procedures more accurate and efficient. An occurrence report is an organizational record of an unusual occurrence or accident that is not a part of the client's record. Integrated plans of care (IPOC) are a combined charting and care plan format. A medication administration record (MAR) is used to document medications administered and their usage.

Answer:

1) Narrative

Rationale:

The nurse used narrative charting when documenting the condition of this newly admitted patient. This format is free text description of the patient status and nursing care. Focus charting highlights the patient's concerns, problems, and strengths in a three-column format. SOAP is an acronym for subjective data, objective data, assessment, and plan. This charting format is used to address single problems or to write summative notes. PIE is an acronym for problem, interventions, and evaluation. This charting method also addresses problems.

Answer:

1) reduces the time nurses spend charting

Rationale:

An advantage of CBE is that it reduces the amount of time that nurses must spend documenting. CBE assumes that unless a separate entry is made, all standards have been met with a normal response. Focus charting addresses the patient's concerns holistically. PIE charting establishes an ongoing care plan from admission. Narrative charting is especially useful when attempting to construct timelines of events.

Answer:

3) discharge needs.

Rationale:

The patient's potential discharge needs should be evaluated when the patient first enters the healthcare facility. After the patient is admitted, discharge needs should be continually reevaluated and documented throughout the patient's hospitalization.

Answer:

3) Narrative notes

Rationale:

The nursing narrative note will contain documentation about the time the medication was administered and the patient's response to the medicine. In contrast, the MAR will only contain documentation about when the medication was given, not the patient's response. The physician's progress note contains documentation about why the furosemide was ordered. The graphic record will not contain charting about the medication but will contain information about the patient's output.

Answer:

3) As needed, but not more than once per hour

Rationale:

The abbreviation for "as needed" is prn. The nurse should administer the medication after assessing that the patient needs the medication or the patient requests it and at least 1 hour has elapsed since the last dose. STAT medications must be administered immediately.

Answer:

1) Injection site

Rationale:

After administering an injection, the nurse must document the injection site to prevent the patient from receiving repeated injections in the same location. Heparin 5,000 units subQ was prescribed for the patient. The previous route of administration is already documented on the MAR from previous dose and would not be noted in the entry for the current dose. The patient's response to medication is recorded in the nurse's narrative note in the traditional paper for electronic health record. When the nurse signs out that the drug was given in the medication administration record, she is validating that she administered the drug according to the physician's order. Heparin does not affect heart rate.

Answer:

3) Draw a line through the error and initial the change.

Rationale:

The nurse should draw a single line through the documentation error and place her initials next to the change. In some institutions, the nurse must also write the words "error" or "mistaken entry" above the error. The nurse should never use opaque cover-up liquid or correction tape. It is not acceptable to alter the patient's health record as though the error had not been made. Making note of the correction in documentation makes it clear to others what happened.

The SOAP(IER) format for nursing and other progress notes is as follows:

1. subjective data
2. objective data
3. assessment
4. plan
5. interventions
6. evaluation
7. revision.

1

Correct!

The most commonly used paper home health documentation form is known as OASIS—the Outcome and Assessment Information Set.

3

Correct!

Integrated plans of care (IPOCs) are a combined charting and care plan form. An IPOC maps out day-by-day patient goals, outcomes, interventions, and treatments for a specific diagnosis or condition from admission to discharge. Lab work, diagnostic testing, medications, and therapies are all included in the pathway, as well as standardized interventions captured in the plan.

1 2 4 6

Correct!

Feedback 1: Members of the interdisciplinary team use the health record to communicate about the patient's status and care.

Feedback 2: Communication promotes continuity of care by allowing you to inform other nurses of a nursing diagnosis for the client.

Feedback 3: Including the names of books the client has recommended to you in your documentation would not be appropriate, as these forms are formal and legal.

Feedback 4: Documentation enables physicians, nurses, and other healthcare professionals to plan and evaluate treatment and monitor health status over time.

Feedback 5: Patients' health information is protected by federal law (HIPAA) and should be kept private, unless the patient has provided written permission to share the information with someone.

Feedback 6: Insurance companies, government and third-party payers, budget managers, and organization billing staff use client health records to determine the cost of care.

2

Correct!

All clients in long-term care facilities must have a comprehensive assessment at admission. Federal law requires that a resident be evaluated using the Minimum Data Set for Resident Assessment and Care Screening within 14 days of admission.

2

Correct!

The Latin term pro re nata is abbreviated as prn, or as needed. Medications that are prn are given only when the patient meets certain conditions that were established in the medication prescription. Typically, medications are prescribed prn for relief of pain, fever, nausea, and constipation.

4

Correct!

Assessments and care may also be recorded on paper and electronic checklists. Common normal and abnormal findings are usually organized according to body systems.

1

Correct!

Patients in hospitals and long-term care facilities receive care from a variety of disciplines, so these institutions commonly use source-oriented records. Members of each discipline record their findings in a separately labeled section of the chart.

3

Correct!

Critics of CBE believe it requires nurses to be overly familiar with the organization's documentation standards and policies.

1 3 5 6

Correct!

Feedback 1: When moving away from an open EHR, close the screen and log out.

Feedback 2: Create a secure password—not something obvious, such as your birth date, Social Security number, or family members' names.

Feedback 3: Change your password at regular intervals even if your organization does not require it.

Feedback 4: Do not share your personal username or password with anyone.

Feedback 5: Do not leave patient data displayed on the screen where others can see it.

Feedback 6: Never access client health records that you have no professional reason to view.

2

Correct!

Narrative charting is especially useful when attempting to construct a time line of events, such as a cardiac arrest or other emergency situations.

1

Correct!

A bedside report, sometimes known as "walking rounds," allows you to observe important aspects of care, such as patient appearance, intravenous pumps, and wounds.

1 2 6

Correct!

Feedback 1: An advantage of a paper health record system is that there is no downtime for system changes or power outages. Because the clinic has frequent power outages, an electronic health record may not be the best choice.

Feedback 2: A disadvantage of electronic health record systems is that they are expensive. The clinic may not have enough funding to support one.

Feedback 3: An advantage of electronic health record systems is that communication is improved among healthcare providers—not only in the facility itself, but also regionally and even globally.

Feedback 4: An advantage of electronic health record systems is that nurses spend up to 25% less time charting.

Feedback 5: An advantage of electronic health record systems is that medical errors are minimized by programmed alerts that are automatically displayed when a care provider takes an action that could be harmful.

Feedback 6: An advantage of an existing paper record system is that care providers are comfortable with it because it is familiar. There is little "learning curve."

2 4 6

Correct!

Feedback 1: Write drug names in full rather than using abbreviations.

Feedback 2: Write out "greater than" or "less than" rather than using the ">" or "<" symbols.

Feedback 3: Use metric units instead of apothecary units.

Feedback 4: Write "at" or "each" rather than use the "@"symbol.

Feedback 5: Write "mL" or "milliliters" in place of the "cc" abbreviation.

Feedback 6: Write "mcg" or "micrograms" instead of the "μg" abbreviation.

3

Correct!

The purpose of giving an oral report is to maintain continuity of care.