Podcast
Questions and Answers
What is documentation defined as?
What is documentation defined as?
The written or printed legal record of all pertinent interactions with the client.
What are three ways health care personnel communicate with one another?
What are three ways health care personnel communicate with one another?
Documentation reflects the quality of care and accountability in providing care.
Documentation reflects the quality of care and accountability in providing care.
True
Which of these is not a way that documentation is used?
Which of these is not a way that documentation is used?
Signup and view all the answers
What is the process of making entry on a client record called?
What is the process of making entry on a client record called?
Signup and view all the answers
The traditional client record is organized by discipline.
The traditional client record is organized by discipline.
Signup and view all the answers
What is the advantage of a source-oriented record?
What is the advantage of a source-oriented record?
Signup and view all the answers
Narrative-chronological notes are a traditional part of the source-oriented record.
Narrative-chronological notes are a traditional part of the source-oriented record.
Signup and view all the answers
Narrative-chronological notes are organized in chronological order.
Narrative-chronological notes are organized in chronological order.
Signup and view all the answers
There is a right or wrong order to the information in narrative-chronological notes.
There is a right or wrong order to the information in narrative-chronological notes.
Signup and view all the answers
What is a "problem-oriented medical record" (POMR) organized around?
What is a "problem-oriented medical record" (POMR) organized around?
Signup and view all the answers
POMR encourages collaboration and the problem list in the front of the chart alerts care givers of the client's needs?
POMR encourages collaboration and the problem list in the front of the chart alerts care givers of the client's needs?
Signup and view all the answers
A disadvantage of POMR is that caregivers differ in their ability to use the required charting format?
A disadvantage of POMR is that caregivers differ in their ability to use the required charting format?
Signup and view all the answers
Another disadvantage of POMR is that it takes constant awareness to maintain an up-to-date problem list?
Another disadvantage of POMR is that it takes constant awareness to maintain an up-to-date problem list?
Signup and view all the answers
POMR is somewhat inefficient because assessments and interventions that apply to more than one problem must be repeated?
POMR is somewhat inefficient because assessments and interventions that apply to more than one problem must be repeated?
Signup and view all the answers
What are the four components of POMR?
What are the four components of POMR?
Signup and view all the answers
The "Data Base" in POMR contains all information known about the client when they first enter the healthcare agency and is updated according to a change in health status?
The "Data Base" in POMR contains all information known about the client when they first enter the healthcare agency and is updated according to a change in health status?
Signup and view all the answers
Problems in POMR are listed in order in which they are identified, redefined as patient condition changed or more data obtained?
Problems in POMR are listed in order in which they are identified, redefined as patient condition changed or more data obtained?
Signup and view all the answers
A "Plan of Care" in POMR is made with reference to the active problem list and is generated by the person who lists the problem?
A "Plan of Care" in POMR is made with reference to the active problem list and is generated by the person who lists the problem?
Signup and view all the answers
In POMR, the plan of care is listed under each problem in the progress note?
In POMR, the plan of care is listed under each problem in the progress note?
Signup and view all the answers
What are progress notes in POMR?
What are progress notes in POMR?
Signup and view all the answers
Progress notes in POMR are numbered to correspond to the problems on the problem list?
Progress notes in POMR are numbered to correspond to the problems on the problem list?
Signup and view all the answers
SOAP format is frequently used in progress notes?
SOAP format is frequently used in progress notes?
Signup and view all the answers
What are the various formats used in progress notes?
What are the various formats used in progress notes?
Signup and view all the answers
What does "SOAP" stand for?
What does "SOAP" stand for?
Signup and view all the answers
PIE groups information into three categories: Problem, Intervention, and Evaluation.
PIE groups information into three categories: Problem, Intervention, and Evaluation.
Signup and view all the answers
The problem statement, intervention, and evaluation in PIE are all numbered the same.
The problem statement, intervention, and evaluation in PIE are all numbered the same.
Signup and view all the answers
An advantage of PIE is that it eliminates traditional CP (care plans) and incorporates an ongoing care plan.
An advantage of PIE is that it eliminates traditional CP (care plans) and incorporates an ongoing care plan.
Signup and view all the answers
A disadvantage of PIE is that all nursing notes should be reviewed before giving care to determine which problems are current and which interventions were effective?
A disadvantage of PIE is that all nursing notes should be reviewed before giving care to determine which problems are current and which interventions were effective?
Signup and view all the answers
Focus Charting is intended to make the client and client concerns and strengths the focus of care?
Focus Charting is intended to make the client and client concerns and strengths the focus of care?
Signup and view all the answers
What are the three columns for recording in Focus Charting?
What are the three columns for recording in Focus Charting?
Signup and view all the answers
What may the "Focus" in Focus Charting be?
What may the "Focus" in Focus Charting be?
Signup and view all the answers
What does DAR stand for in Focus Charting?
What does DAR stand for in Focus Charting?
Signup and view all the answers
The "Data" in DAR represents the assessment phase of care?
The "Data" in DAR represents the assessment phase of care?
Signup and view all the answers
The "Action" in DAR represents planning and implementation of care?
The "Action" in DAR represents planning and implementation of care?
Signup and view all the answers
The "Response" in DAR represents the evaluation phase?
The "Response" in DAR represents the evaluation phase?
Signup and view all the answers
Charting by Exception (CBE) is a documentation system where only abnormal or significant findings are recorded?
Charting by Exception (CBE) is a documentation system where only abnormal or significant findings are recorded?
Signup and view all the answers
What are the three components of CBE?
What are the three components of CBE?
Signup and view all the answers
An advantage of CBE is that it eliminates the need for lengthy, repetitive notes?
An advantage of CBE is that it eliminates the need for lengthy, repetitive notes?
Signup and view all the answers
Another advantage of CBE is that it makes client changes in condition more obvious?
Another advantage of CBE is that it makes client changes in condition more obvious?
Signup and view all the answers
Computerized Documentation (Electronic Health Records) is used to store clients' databases, add data, create, and revise CPs, and document client progress?
Computerized Documentation (Electronic Health Records) is used to store clients' databases, add data, create, and revise CPs, and document client progress?
Signup and view all the answers
Computerized Documentation makes care planning and documentation easy?
Computerized Documentation makes care planning and documentation easy?
Signup and view all the answers
Computerized Documentation makes transmission of information from one care setting to another possible?
Computerized Documentation makes transmission of information from one care setting to another possible?
Signup and view all the answers
A disadvantage of Computerized Documentation is that client privacy may be infringed on if security measures are not used?
A disadvantage of Computerized Documentation is that client privacy may be infringed on if security measures are not used?
Signup and view all the answers
Computerized Documentation can cause breakdowns that make information temporarily unavailable?
Computerized Documentation can cause breakdowns that make information temporarily unavailable?
Signup and view all the answers
A disadvantage of Computerized Documentation is that the system is expensive?
A disadvantage of Computerized Documentation is that the system is expensive?
Signup and view all the answers
A disadvantage of Computerized Documentation is that training is required when a new or updated system is installed?
A disadvantage of Computerized Documentation is that training is required when a new or updated system is installed?
Signup and view all the answers
Case Management uses a multi-disciplinary approach to planning and documenting client care, using a critical pathway?
Case Management uses a multi-disciplinary approach to planning and documenting client care, using a critical pathway?
Signup and view all the answers
Case Management identifies the outcome expected to be achieved for certain groups of clients on each day of care?
Case Management identifies the outcome expected to be achieved for certain groups of clients on each day of care?
Signup and view all the answers
Case Management uses critical pathways, graphics, and flow sheets.
Case Management uses critical pathways, graphics, and flow sheets.
Signup and view all the answers
Case Management promotes collaboration and teamwork among caregivers, helps decrease length of stay, and makes efficient use of time.
Case Management promotes collaboration and teamwork among caregivers, helps decrease length of stay, and makes efficient use of time.
Signup and view all the answers
Case Management is best suited for patients with one or two diagnoses and few needs.
Case Management is best suited for patients with one or two diagnoses and few needs.
Signup and view all the answers
Clients with multiple diagnoses are difficult to document on a critical pathway.
Clients with multiple diagnoses are difficult to document on a critical pathway.
Signup and view all the answers
Reporting is the purposeful communication of specific information to a person or group of people.
Reporting is the purposeful communication of specific information to a person or group of people.
Signup and view all the answers
Reports should be concise and include pertinent information, excluding extraneous details.
Reports should be concise and include pertinent information, excluding extraneous details.
Signup and view all the answers
What are the four types of reporting?
What are the four types of reporting?
Signup and view all the answers
A Change of Shift Report is a report given to all nurses on the next shift.
A Change of Shift Report is a report given to all nurses on the next shift.
Signup and view all the answers
The purpose of a Change of Shift Report is to provide continuity of care for patients.
The purpose of a Change of Shift Report is to provide continuity of care for patients.
Signup and view all the answers
A Change of Shift Report can be written or given orally.
A Change of Shift Report can be written or given orally.
Signup and view all the answers
A Change of Shift Report is sometimes given at the bedside, where the client and nurse participate in the information exchange?
A Change of Shift Report is sometimes given at the bedside, where the client and nurse participate in the information exchange?
Signup and view all the answers
When a nurse receives a telephone report, it's important to document the date and time, the person providing the information, the subject of the information, and then sign the notation.
When a nurse receives a telephone report, it's important to document the date and time, the person providing the information, the subject of the information, and then sign the notation.
Signup and view all the answers
It's important to repeat information received in a telephone report back to the sender to ensure accuracy.
It's important to repeat information received in a telephone report back to the sender to ensure accuracy.
Signup and view all the answers
A telephone report should be concise and accurate, starting with the patient's name and relationship to the client.
A telephone report should be concise and accurate, starting with the patient's name and relationship to the client.
Signup and view all the answers
A telephone report should include the patient's name, medical diagnosis, vital signs, and significant lab data.
A telephone report should include the patient's name, medical diagnosis, vital signs, and significant lab data.
Signup and view all the answers
When a nurse receives a telephone report, it's important to make the patient's record readily available for the physician.
When a nurse receives a telephone report, it's important to make the patient's record readily available for the physician.
Signup and view all the answers
After receiving a telephone report, the nurse should document the date and time and the content discussed during the call.
After receiving a telephone report, the nurse should document the date and time and the content discussed during the call.
Signup and view all the answers
A physician who prescribes therapy over the phone is giving a "telephone order" (TO).
A physician who prescribes therapy over the phone is giving a "telephone order" (TO).
Signup and view all the answers
The nurse who receives a telephone order should transcribe it onto the physician order sheet and indicate it as "verbal order" (VO) or "telephone order" (TO).
The nurse who receives a telephone order should transcribe it onto the physician order sheet and indicate it as "verbal order" (VO) or "telephone order" (TO).
Signup and view all the answers
The physician who gives a telephone order should sign it within 24 hours.
The physician who gives a telephone order should sign it within 24 hours.
Signup and view all the answers
What information should be included when documenting a telephone order?
What information should be included when documenting a telephone order?
Signup and view all the answers
A Care Plan Conference is a meeting of a group of nurses to discuss possible solutions to certain problems of a client.
A Care Plan Conference is a meeting of a group of nurses to discuss possible solutions to certain problems of a client.
Signup and view all the answers
Nursing Rounds are a procedure in which two or more nurses visit selected clients at the bedside.
Nursing Rounds are a procedure in which two or more nurses visit selected clients at the bedside.
Signup and view all the answers
What are the objectives of Nursing Rounds?
What are the objectives of Nursing Rounds?
Signup and view all the answers
What is the primary goal of documentation and reporting?
What is the primary goal of documentation and reporting?
Signup and view all the answers
Study Notes
Documentation & Reporting (NUR 102)
- Documentation is defined as the written or printed legal record of all interactions with the client.
- It reflects the quality of care and accountability in providing care.
- Healthcare professionals communicate through discussions, reports, and records (charts or client records).
- Discussion is informal oral consideration of a subject by multiple healthcare professionals to resolve problems or develop strategies.
- A report is oral, written, or computer-based communication to convey information to others.
- A record (chart or client record) is a formal legal document that documents care. It can be written or computer-based.
- Recording, charting, or documenting is the process of making entries in a client's record.
Documentation Purposes
- Communication: Sharing information.
- Planning client care: Using data from records to plan care.
- Auditing health agencies: Reviewing records for quality assurance.
- Research: Using data as a valuable research resource.
- Education: Students use client records as educational tools.
- Legal documentation: Used in court as evidence.
- Reimbursement: Obtaining payment, accurate diagnosis-related group codes and appropriate care must be documented.
- Health care analysis: Identifying health care agency needs, costly/revenue-generating services.
Documentation Systems
- Source-Oriented Record: Traditional client record, organized by discipline. Each person/department makes notes in their section of the chart.
- Advantage: Easy to locate discipline-specific information.
- Disadvantage: Not organized by client problem, making tracking difficult, fragmented, repeating information, lack of coordination of care, and incomplete picture of client's care.
- Problem-Oriented Medical Record (POMR): Documentation focused on client problems, rather than source of information from all disciplines.
- Advantage: Encourages collaboration, alerts care givers to client needs, makes tracking easier.
- Disadvantage: Caregivers may differ in their ability to use required format, constant awareness of problem list needed, inefficient if assessments and interventions apply to more than one problem.
- Components: Database, Problem list, Plan of care, Progress note.
- Problem, Intervention, Evaluation (PIE): Groups information into three categories: problem, intervention, and evaluation. All nursing documentation uses the same numbering system.
- Advantages: Eliminates traditional CP and incorporates an ongoing care plan.
- Disadvantages: Must review all nursing notes to determine which problems and interventions are current.
- Focus Charting: Focuses on client and their concerns and strengths. Three columns: date/time, focus, and progress note. Progress notes are organized into DAR: Data (assessment), Action (planning/implementation), and Response (evaluation).
- Charting by Exception (CBE): Only abnormal or significant findings are documented, eliminating repetitive charting.
- Computerized Documentation (Electronic Health Records - EHRs): Stores client database, adds data, revises care plans, and documents client progress. Facilitates care planning and documentation, improves transmission of information.
- Advantages: More efficient use of time, facilitates focus on client outcomes, permits immediate checking of orders before administering treatment or medication.
- Disadvantages: Client privacy may be violated if security measures are not used, system breakdowns temporarily make information unavailable, costly during installation/training period.
Case Management
- Multidisciplinary approach to planning and documenting client care using critical pathways, identifying anticipated outcomes and using flow sheets, and graphics.
- Promotes collaboration and teamwork.
- Efficient use of time, decreases length of stay.
- Effective for clients with one or two diagnoses and few needs.
- Not effective or practical for clients with multiple diagnoses.
Documenting Nursing Activities
- Admission Nursing Assessment
- Nursing Care Plans
- Kardex
- Flow Sheets
- Progress notes
- Nursing discharge/referral
General Guidelines for Recording
- Date and time
- Timing (frequency)
- Legibility
- Permanence (use dark ink)
- Accepted terminology
- Accurate spelling and correct use of titles
- Signature
- Sequence
- Completeness
- Conciseness
- Legal prudence
Correcting Errors in Charting
- Single line through error
- Write "error" above entry
- Date, time, and initial the correction
Reporting
- Purpose: Communicate specific information to a person or group of people.
- Should be concise and include pertinent information.
- Includes: Change of Shift Report, Telephone Report, Care Plan Conference, and Nursing Round.
Telephone Orders (TO)
- Physician communicates prescribed therapy over the phone, transcribed to order sheet as verbal order (VO) or (TO), and signed by physician.
- Includes: date, time, stated order, signature and credentials of nurse, and name of physician.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Related Documents
Description
This quiz covers the essential aspects of documentation and reporting in nursing. It addresses the importance of written records, the types of communication among healthcare professionals, and the purposes of documentation in patient care and quality assurance. Test your knowledge on how effective documentation impacts nursing practice.
