Shared Flashcard Set

Details

Documentation
DATA COLLECTION and DOCUMENTATION Jim McCarragher
61
Nursing
Undergraduate 1
09/08/2011
Click here to study/print these flashcards.

Create your own flash cards! Sign up here.

Additional Nursing Flashcards

 

 

Cards

Term
AMA:
 Definition
Against Medical Advice
Term
(POMR OR POR):
 Definition
PROBLEM-ORIENTED
Term
6 "W"s of documentation
 Definition
‘WHEN, WHERE, WHAT, WHY, HOW AND WHO’
If all the six questions are answered, you have a complete documentation entry!
Term
ABBREVIATIONS:
 Definition
Use accepted facility abbreviations (see Text) for commonly used abbreviations.)
Term
ADPIE
 Definition
Assessing,
Diagnosing
Planning,
Implementing,
Evaluating
Term
AS AN ADN STUDENT HOW SHOULD I SIGN MY ENTRY?
 Definition
Clay Bradley, ASN-1, RVCC
Term
All health care team members contribute to:
 Definition
–    Baseline Data: subjective/objective
–    Problem List
–    Initial List of Orders or Care Plan
–    Progress Notes
Term
(Nursing Diagnosis)/Assessment:
 Definition
Statement of the problem, patient condition.
Term
Basic principles of interviewing:
 Definition
Attitude of the interviewer, application of the interview process, communicating at the client’s level of understanding considering the developmental level/age of the client (child, adult, elderly)
Term
CASE MANAGEMENT:
 Definition
A role of the RN that promotes collaboration and teamwork. It includes reporting, coordination, directing, conferring and referring regarding patient care.
Term
CBE:
 Definition
Charting by Exception only those conditions (significant findings) that deviate from the patient’s normal status.
Term
CHANGE OF SHIFT REPORT:
 Definition
May be Taped/Verbal. Concise, organized, thorough sharing of information among professionals.
Term
CRITICAL PATHWAYS:
 Definition
Patient Outcome Charting: For specific diagnoses, desired outcomes are identified for each day of hospitalization.
Term
D A R
 Definition
Data (assessment) Action Response
Term
DATA COLLECTION METHODS:
 Definition
Observing
Interviewing
Examining
Term
Data (assessment) Action Response
 Definition
Focus Charting: Process-oriented, focused on the nursing process and allows for broader identification of problems that concern the nurse.
Data: Assessment Action
Response
Term
Differentiate among the various types of interviewing questions
 Definition
Open-ended, pt fills in
closed, y/n
validating,
clarifying, what do ya mean by that?
reflecting,
sequencing,
directing
Term
Documentation doesn't count if it isn't:
 Definition
done, legible, accurate and meaningful.
Term
Documentation/ BE ACCURATE: Always note the:
 Definition
MILITARY date/time of the entry.
Term
Documentation/ F A C T:
 Definition
Factual, Accurate, Complete & Timely
Term
Documentation/CHRONOLOGICAL ORDER
 Definition
must be followed for all entries. Indicate as ‘Late Entry’ if you must document out of order. DO NOT SKIP LINES!
Term
EMR ADVANTAGES:
 Definition
Adapting to increased data,
Decreasing fragmentation of Information
Increased storage capacity,
Total accessibility,
Immediate current information,
Medical alerts and reminders, Customized views of relevant information
Improvements in risk management, and assessment outcomes,
Accurate billing and electronic submission of billing with rapid payment
Happier patients with decreased redundancy
Term
EMR CONCLUSION:
 Definition
“The EMR provides the essential infrastructure required to enable the adoption and effective use of new healthcare modalities and information management tools such as integrated care, evidenced-based medicine, computer-based decision support, care planning and pathways, and outcomes analysis”
Term
EMR DISADVANTAGES:
 Definition
Start up costs computers and training
Usability by all
Substantial learning curve
Confidentiality and Security
Placement of Hardware and portability
Term
EMR ISSUES
 Definition
Lack of a common vision and lack of definition of the EMR
Lack of standardized terminology, system architecture and indexing
HIPPAA 1996 called for the adoption of “standards for unique health identifiers, confidentiality policies and terminology”
Term
ERRORS:
 Definition
Clearly note any mistakes that are made by drawing one line through the mistake and writing ‘mistaken entry’ or ‘disregard’ above it, the date, and your initials/name per agency policy.
Term
FREQUENCY & CONTENT:
 Definition
The health care professional should chart every time that additional assessment data is collected.
Term
GUIDELINES FOR RECORDING:
 Definition
BE CLEAR
BE CONCISE
BE ACCURATE
MILITARY TIME
BE LEGIBLE
BLACK INK
CLAY BRADLEY ASN-1, RVCC
Term
HIPAA
 Definition
(Health Insurance Portability and Accountability Act)
Term
INCIDENT REPORT/ Purpose:
 Definition
identifies ways to prevent future incidents/accidents. Record information (but not that an incident report was completed) in chart as well.
Term
INCIDENT REPORT:
 Definition
An agency record of an accident or unusual occurrence. Alerts risk management.
Term
INFORMED CONSENT:
 Definition
An agreement by the client to accept a course of treatment or procedure after receiving complete information.
Term
KARDEX:
 Definition
Concise easy to access method of updated data that serves as a daily communication among caregivers of patient care needs
–    Done in pencil (unless computerized)
–    Update each shift
Term
Label each page of the health record with:
 Definition
patient’s complete name, physician's name and health record number.
Term
List the phases of the interview process
 Definition
Opening: establish rapport, orientation
The Body
The Closing
Term
NARRATIVE CHARTING:
 Definition
Good for routine care, normal findings
•    Disadvantage: Information related to a specific problem is found in multiple places
Term
Objective:
 Definition
Measured or observed (e.g., Patient did not eat lunch, patient moving in bed frequently from side to side, abdomen warm to touch, etc.)
Term
Other RN roles/ NURSING ROUNDS:
 Definition
2 or more nurses go to patient bedside and include patient in conference.
Term
PCP
 Definition
PRIMARY CARE PROVIDER
Term
PIE, APIE:
 Definition
Problem Intervention Evaluation Charting: Assessment: Combines subjective and objective data
Problem: Nursing Dx
Interventions Evaluation
Term
PROBLEM-ORIENTED
 Definition
PROBLEM-ORIENTED (POMR OR POR): Data is arranged according to the problems the client has vs. the source of information. Encourages collaboration with other team members.
Term
PURPOSES OF DOCUMENTATION
 Definition
COMMUNICATES ASSESSMENT DATA to all members of the health care team
PROVIDES EVIDENCE FOR EVALUATION
PURPOSES:
SERVES AS A PERMANENT RECORD FOR LEGAL DOCUMENTATION and FINANCIAL PURPOSES
Term
PURPOSES OF DOCUMENTATION
 Definition
HELPS ASSURE CONTINUITY AND QUALITY OF RESIDENT CARE May be used to AUDITThe purpose of an audit is to compare actual nursing care to established standards.
Term
PURPOSES OF DOCUMENTATION
 Definition
COMMUNICATES ASSESSMENT DATA to all members of the health care team. This helps prevent overlaps, repetition and gaps in care.

PROVIDES EVIDENCE FOR EVALUATION PURPOSES: In addition, records and reports assist department heads and administrators to evaluate performance of health care personnel.
Documentation helps assure the public of the scope and quality of health care and helps convey what the staff actually does.
Term
Plan: Towards resolution of the problem (measurable, time specific) which involves:
 Definition
Intervention: Specific
Evaluation
Revisions: Based on evaluation.
Term
Progress notes are the only place where documentation supports whether:
 Definition
orders are carried out, and what the results are.
Term
Pt found on floor; Incident report
 Definition
overview of incident and factors that contributed to incident.
Term
Pt found on floor; Nursing notes
 Definition
document what happened to the patient and what you did.
Term
Recall principles of effective interviewing
 Definition
Process: Setting the climate, time limit, establishing the purpose/goals, summarizing
Basic principles of interviewing: Attitude of the interviewer, application of the interview process, communicating at the client’s level of understanding considering the developmental level/age of the client (child, adult, elderly)
Term
Rose Shannon 6 Ws
 Definition
When:   11/01/XX 0800
Where:  Mt. Ascutney Hospital, Nursing Home Unit
What:   Change in routine, interest in life
Why:     Explore with resident (plan)
How:   Plan: By spending more time talking with Rose and getting feedback about her current feelings and needs at this time.
Who: Kris Kringle, ADN1, RVCC
Term
Rose Shannon Care Plan
 Definition
Rose Shannon
ID #: 092949
Mt. Ascutney Hospital
Nursing Home Unit
11/01/XX: 0800-------------------------------------------------------------------------------------------------
S: “I’m tired of being sick. I wish I could end it all and be with my husband.” --------------------
O: Resident has not been participating in activities, is not interested in her morning routine and has eaten 50% of her meals in the last week. She is not as engaging with others and sleeps a lot during the day. Weight loss since 10/1 is 6 lbs.----------------------------------------------------
A: Disturbed body image r/t Powerlessness AMB changes in eating, sleeping, activities, appearance and affect ------------------------------------------------------------------------------------------
P: Spend more time talking to Rose and obtain feedback about her current feelings and needs at this time. --------------------------------------------------------------------------------------------------------
Short term Goal: By 11/8 resident will share her concerns and express her needs. Staff will revise her care plan and work with her on her current goals.------------------------------------------
term Goal: If there is no change by 11/15, discuss with PCP a client consult for medication to help her during this period of adjustment---------------------------------------------------------------
Kris Kringle, ADN1, RVCC-------------------------------------------------------------------------------
Term
SOAPIER
 Definition
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLAN
INTERVENTION
EVALUATION
REVISION
Term
SOURCE-ORIENTED:
 Definition
(traditional). The practitioner (e.g., nurse, dietician, etc.) is the source of the data. Separate sections of patient’s chart by department .
Term
Studies have shown that where there is poor documentation,
 Definition
there is likely to be poor care.
Term
Subjective:
 Definition
Patient’s own words, perceptions (e.g., Patient states ‘I feel sick to my stomach’
Term
TELEPHONE ORDERS:
 Definition
TO RN only. Write down complete order on doctor’s order sheet, then repeat it back to PCP and receive confirmation from the individual who gave the order.
Must be signed by MD, NP, PA usually within 24 hours
Term
THE NURSING PROCESS →
 Definition
Assessing, Diagnosing, Planning, Implementing, Evaluating
Term
WHAT ARE THE VARIOUS TYPES OF INTERVIEWING QUESTIONS?
 Definition
Open-ended, closed,
validating, clarifying,
reflecting,
sequencing,
directing
Term
WHAT IS THE LEGAL STANDARD FOR NURSING STUDENTS?
 Definition
SAME AS THE RN
Term
What are the phases of the Interview Process?
 Definition
Opening: establish rapport, orientation
The Body
The Closing
Term
What’s in a Medical Record?
 Definition
Admission data, Advance Directives
Doctor’s Orders
Care Plan with Behavioral Outcomes
Graphic sheet, flow sheet
ProgressNotes(interdisciplinary) Diagnostic test results
Referrals, Discharge/Transfer Summary
Other
Supporting users have an ad free experience!