Term
| Guidelines for Documentation |
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Definition
➢ Factual Basis
➢ Accuracy
➢ Completeness
➢ Currentness
➢ Organization
➢ Confidentiality
➢ Avoid Bias Statements
➢ Spell correctly
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Term
| what terms to avoid when charting |
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Definition
| appears, seems, apparently |
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Term
| how to correct an error when charting |
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Definition
draw a single line trough it, write "error" above it and sign initials and date it.
DO NOT USE CORRECTION FLUID OR ERASE |
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Term
| if order is questioned what should you do? |
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Definition
| record that clarification was sought, DO NOT record "physician made error", include date and time of phone call, whom you spoke with, and the outcome |
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Term
| what generalized phrases should be avoided when charting? |
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Definition
| "status unchange" or "had good day"; use complete concise descriptions so documentation is objective and factual |
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Term
| begin each documentation entry with |
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Definition
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Term
| end each documentation entry with |
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Definition
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Term
| flow sheets offer a means to |
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Definition
| enter current information quickly |
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Term
| activities or findings to communicate at the time of occurrence include: |
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Definition
vital signs
administratios of meds and treatments
preparation for tests or surgery
change in pt status and who was notified
admission, transfer, discharge, death
treatment for sudden change in pt. status
pt's response to treatment or intervention |
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Term
| some spelling errors can result in |
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Definition
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Term
| TJC standards require that all entries in medical records are |
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Definition
| dated and a method is established to identify the authors of entries |
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Term
| if info is inadvertently omitted from the record, is it acceptable for nurses to ask colleagues to chart infor after they leave work? |
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Definition
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Term
| Examples of Progress Notes Written in Different Formats |
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Definition
SOAP - subjective, objective, assessment, plan
PIE - problem, intervention, evaluation
DAR - (focus charting) - data, action, response |
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Term
| the traditional method for recording nursing care |
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Definition
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Term
| disadvantages of narrative charting |
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Definition
repititous info
time consuming
requires reader to sort through info to locate data
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Term
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Definition
➢ Narrative
➢ Problem-oriented
➢ Charting by Exception
➢ Critical Pathways
➢ Computerized |
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Term
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Definition
➢ Story-like format in chronological order
➢ Format…
o Initial entry
o Physical Assessment
o Description of events
o Black ink, no skipped lines, sign each entry
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Term
| Problem oriented medical record (POMR) |
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Definition
emphasizes pt's problems: 4 major sections:
➢ Database
➢ Problem list
➢ Nursing Care Plan
➢ Progress Notes |
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Term
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Definition
| contains all available assessment info pertaining to pt (e.g., history, physical exam., admission history, ongoing assessment, lab reports, test results); it is the foundation for indentifying client problems and planning care; it accompanies pt's through successive hospitalizations and clinic visits |
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Term
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Definition
| includes pt's physiological, psychosocial, social, cultural, spiritual, developmental, and environmental needs; the problems are listed in chronological order |
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Term
| the problem list is filed where |
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Definition
| in front of the client's record to serve as an organizing guide for the client's care |
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Term
| when a problem on the problem list is resolved.. |
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Definition
| record the date and highlight it or draw a line through the problem and its number |
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Term
| PIE is different from SOP in that |
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Definition
| PIE charting has a nursing origin, whereas SOAP originated from medical records |
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Term
| PIE notes are numbered and labeled according to |
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Definition
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Term
| focus charting uses waht type of progress note? |
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Definition
| DAR; which addresses pt concerns: a sign or symptom, a condition, a nursing diagnosis, a behavoir, a significant event, or change in pt condition |
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Term
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Definition
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Term
| benefits of focus charting |
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Definition
| it incorporates all aspects of nursing process, highlights the pt's concerns, and can be integrated into any clinical setting |
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Term
| in a source record, the pt's chart has a |
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Definition
| separate section for each discipline to record data |
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Term
| advantage of a source record |
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Definition
| caregivers can easily locate the proper section of the record in which to make entries |
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Term
| disadvantage of a source record |
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Definition
| details about a problem are distributed throughout the record |
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Term
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Definition
| focuses on documenting deviations from the established norm or abnormal findings; it reduces documentation time and highlights trends or changes in pt's condition |
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Term
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Definition
| incorporates multidisciplinary approach to documenting client care |
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Term
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Definition
| multidisciplinary care plans that include client problems, key interventions, and expected outcomes with and established time frame; they eliminate nurses' notes, flow sheets, and care plans b/c the pathway document integrates all relevant information |
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Term
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Definition
| unexpected outcomes, unmet goals, and interventions not specified within critical pathway time frame |
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Term
| focus notes are used on flow sheets when |
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Definition
| an occurence is unusual or changes significantly |
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Term
| flow sheets are commonly used in |
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Definition
| crictical care and acute care units for all types of physiological data |
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Term
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Definition
info accessible to all memebers of health care team
decreases time spent on narrative note
info is current
decreases errors resulting from transfer of info
team members can quickly see trends over time |
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Term
| Kardex (client care summary) |
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Definition
| portable flipover file or notebook, kept at nurses station |
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Term
| an updated Kardex eliminates |
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Definition
| the need for repeated referral to the chart for routine info throughout the day; done in pencil unless it's a permanent part of pt's record |
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Term
| Kardex includes the following info: |
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Definition
demographic data
HIPAA code word
health care provider's name
primary medical dx
medical and surgical history
current treatment orders
care plan
nursing orders
scheduled tests and procedures
safety precautions for pt
factors related to ADL's
emergency contact
emergency code status
allergies
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Term
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Definition
| offer a way to determine the hours of care and staff required for a given group of clients |
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Term
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Definition
| the type and number of nursing interventions required over a 24 hr period |
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Term
| is a 1 or 5 acuity level more critical? |
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Definition
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Term
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Definition
| based on the institution's standards of nursing practice, are preprinted, established guidelines that are used to care for clients who have similar health problems |
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Term
| advantages of standardized care plans |
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Definition
| the establishment of clinically sound standards of care for similar groups of clients (these standards are useful when conducting quality improvement audits); education (nurse learns to recognize the accepted requirements of care for clients); can also improve continuity of care among professional nurses |
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Term
| disadvantage of standardized care plans |
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Definition
| inhibits nurses' identification of unique, individualized therapies for clients |
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Term
| standardized care plans CANNOT |
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Definition
| replace the nurse's professional judgement and decision making |
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Term
| Discharge planning should begin at |
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Definition
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Term
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Definition
-clear, concise descriptions
-step by step procedure processes
-identify precautions for self care or med admin.
-review signs that should be reported
-list names and numbers of health care providers
-identify any unresolved problems
-list time of discharge, mode of transport, and who accompanied the pt.
-the pt and family's responsiblities for pt care
-med instructions-when, why, dose, route, precautions, possible reactions, when and how to get prescriptions filled
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Term
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Definition
change-of-shift reports
telephone reports
transfer reports
incident reports |
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Term
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Definition
| orally in person, by audiotape, or during "walking-planning" rounds at each pt's bedside |
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Term
| Example of change-of-shift report includes: |
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Definition
1. Background Info
2. Assessment
3. Nursing Dx
4. Teaching Plan
5. Treatments
6. Family Info
7. Discharge plan
8. Priority needs
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Term
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Definition
| often given by phone when pt is switching units |
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Term
| what not to do in a change-of-shift report: |
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Definition
-DON'T REVIEW ALL ROUTINE CARE PROCEDURES
-DONT REVIEW ALL BIOGRAPHICAL INFO ALREADY WRITTEN
-DON'T USE CRITICAL COMMENTS ABOUT PT BEHAVIOR
-DON'T MAKE ASSUMPTIONS ABOUT RELATIONSHIPS B/W FAMILY
-DON'T DESCRIBE BASIC STEPS OF PROCEDURE
-DON'T USE "GOOD" OR "POOR" BE SPECIFIC
-DON'T LEAVE OUT PRIORITIES
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Term
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Definition
| defined by the ANA as a specialty that integrates nursing science, computer science, and info science to manage and communicate data, info, and knowledge in nursing practice |
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