Term
| True or False. When documenting, make sure to include subjective and objective data. |
|
Definition
| True. All data must be patient orientated and non-opinionated. |
|
|
Term
| True or False. When documenting, you can use a blue pen. |
|
Definition
| False. only black pens allowed. |
|
|
Term
| True or False. Only military time is acceptable when documenting. |
|
Definition
| True. if standard time is used hours can be confused. |
|
|
Term
| True or False. When you document a symptom, you must also document what you did about it. |
|
Definition
| True. Documenting a symptom without a solution is confusing to an oncoming nurse. The nurse doesn't know if you did or did not do anything about it. |
|
|
Term
| True or False. To save time, it's okay to document what you are going to do for the patient before you do it. |
|
Definition
| False. you may forget to do something that you said you would do. |
|
|
Term
| True or False. document an issue with another nurse. |
|
Definition
| false. documenting is patient based. argueing with another nurse has nothing to do with the patient. |
|
|
Term
| true or false. A copy of an incident report must be placed in a patient's records. |
|
Definition
| false. incident reports are important for Hospital QC, not for patient care. |
|
|
Term
| True or False. when a mistake has been made in a record, cross it out and write mistake above it and initial. |
|
Definition
| True. White out is prohibited when charting. |
|
|
Term
| True or False. when documenting a patients interactions with another person in the same room, state the persons name in your patient's chart. |
|
Definition
| False. state roomate, think confidentiality. |
|
|
Term
| True or False. When running behind, it is okay to ask another nurse to help you document. |
|
Definition
| False. only you can report on what you have done. Another nurse may add information about your care for a patient and you did not do it. |
|
|
Term
| True or False. after recieving verbal orders from a doctor, the doctor must have them signed within 24 hours. |
|
Definition
| True a verbal order must always be verified. |
|
|
Term
| What are the types of nursing charts? |
|
Definition
| nurses notes, narative note, kardex, flow sheets, discharge notes, progess summaries. |
|
|
Term
What kind of note is this?
Patient states, "I'm having a hard time catching my breath." Respirations labored at 32/min, p.120, BP 112/70. Using intercostal muscles during inhalation. Breath sounds with crackles and wheezes over both lower lobes. Oxygen saturation 90%. Elevated HOB to 45 degrees and started oxygen at 2L/min via N/C. Patient states "I'm feeling a little better" after oxygen started. Oxygen saturation still 90%. Call placed to Dr. Crutchmeyer. -------------K. Hudson, MSN, RN, CMSRN |
|
Definition
|
|
Term
| What is a source orientated medical record? |
|
Definition
| Each person or department makes notations in a separate section of one single chart (nursing, medicine, social work, PT, etc) |
|
|
Term
| What is a problem orientated note? |
|
Definition
| Data about the client is arranged according to the client health problems. |
|
|
Term
| What are the four components of a problem-orientated note? |
|
Definition
| baseline data, problem list with prioritization, initial list of orders and care plans for each problem, progress notes. |
|
|
Term
| What does SOAP stand for? |
|
Definition
| subjective, objective, assessment, plan |
|
|
Term
|
Definition
| problem, intervention, evaluation |
|
|
Term
| What does APIE stand for? |
|
Definition
| assessment, problem, intervention, evaluation. |
|
|
Term
|
Definition
| Method of identifying and organizing narrative documentation to include DAR (data includes subjective and objective; action includes interventions and treatments; response is focused on the patient's response to the nursing care and medical treatment) |
|
|
Term
| What are the benefits of computer documenting? |
|
Definition
| increased legibility, less room for error, easily transferable. |
|
|
Term
| What are the cons to computer documenting? |
|
Definition
| people tend to not evaluate the note taking and think its correct (medications) difficult access for student nurses. |
|
|
Term
| What is charting by exception? |
|
Definition
| Document only deviations of a patient's care and health. Assumes that all standards of care were met. |
|
|
Term
| How can you be sure your documentation is satisfactory? |
|
Definition
| evaluate making sure your documentation is: chronological, comprehensive, complete(signatures,dates,times), concise, descriptive, factual, legally aware, legible, relevant, standard abbreviations, symbols, and terms, thorough, timely, confidential, accurate. |
|
|
Term
| If a patient refuses to sign AMA (against medical advice) what should you do? |
|
Definition
| Have another nurse witness refusal and document. |
|
|
Term
| What do you include in a change of shift report? |
|
Definition
Patient's name, room #, age, background information, diagnosis, doctor (optional, but good info)
Health status,Significant assessment
Teaching, Treatments ,Outcomes of care
Equipment like IVs, catheters, tubes
Tests and procedures
Special discharge plans including family information |
|
|
Term
| What does SBAR stand for and what is it used for? |
|
Definition
| Situation, background, assessment, recommendation. when giving a shift change report. |
|
|
