Questions and Answers
What is the purpose of clinical pathways?
Allow the development of integrated care plans for a projected length of stay.
Which document should the nurse manager check to verify the patient's progress?
Flow sheet
What document could be temporarily used to provide answers regarding the patient's condition if the paper chart is missing?
Kardex or Rand
Which acronym best suits the new approach to documenting patient progress notes?
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What should the nursing assistant do about the patient chart upon discharge?
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What action should the nurse take if a patient did not receive a morning dose of insulin?
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During which phase of the nursing process does provision of nursing care take place?
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Which patient charting method does the nurse manager suggest if there is a lot of abnormal patient data?
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Which charting method does a facility follow if it states the problem, intervention, and evaluation of treatment?
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What document would help the nurse gather information about health status and interventions from the previous shift?
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Which part of the documentation should the nurse manager look into when auditing nursing care?
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What format of documentation reflects the use of the same progress notes, flow sheets, and narrative notes by a care team?
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In focus charting, which component did the nurse miss documenting when updating only the data and action component?
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How should the nurse rewrite the statement, 'The patient tolerated the walker well'?
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Which protocol allows a patient to acquire access to his or her medical record?
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Study Notes
Clinical Pathways
- Clinical pathways facilitate the creation of integrated care plans focused on anticipated length of stay.
Patient Progress Reports
- Nurse managers should refer to the flow sheet to verify patient progress, as it tracks routine assessments, treatments, and care.
Missing Paper Chart
- In the absence of a paper chart, a Kardex or Rand can be used temporarily to access patient information, prescriptions, and treatment details.
Documentation Approach
- SOAPIER is a recommended acronym for documenting patient progress notes, encompassing Subjective information, Objective data, Assessment, Plan, Implementation, Evaluation, and Revision.
Patient Discharge
- The nursing assistant is responsible for sending the patient's chart to medical records upon discharge.
Incident Reporting
- If a medication dose is missed, the immediate action for the nurse is to complete an incident report following hospital policy.
Nursing Process Phase
- The implementation phase of the nursing process is where nursing care is provided.
Charting Method
- For managing abnormal patient data, the suggested charting method is Charting by Exception.
PIE Charting
- The facility utilizes the PIE charting method, which organizes documentation into Problem, Intervention, and Evaluation.
Shift Handover
- A relief nurse can refer to the SBAR (Situation, Background, Assessment, Recommendation) document to understand patient health status and interventions from the prior shift.
Auditing Nursing Care
- To evaluate whether nursing care meets accepted standards, the nurse manager should examine the Nurse's Notes.
Documentation Formats
- A care plan developed by a team in an acute care facility using consistent progress notes and flow sheets reflects a Problem-oriented Medical Record (POMR) format.
Focus Charting
- In a focus charting system, the nurse must include all three components: Data, Action, and Response. Missing the Response limits the evaluation of intervention outcomes.
Clear Record Keeping
- Statements in patient records should be specific. For instance, "The patient walked the entire stretch of the hall using the walker without any problems" is preferable to vague phrases.
Access to Medical Records
- Patients can gain access to their medical records by submitting a written request.
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Description
This quiz features flashcards focusing on key concepts from Chapter 3 about clinical documentation. It covers topics such as clinical pathways and the role of flow sheets in patient care. Test your knowledge and ensure you understand essential nursing documentation practices.
