Documentation & Reporting (NUR 102)

What is documentation defined as?

What are three ways health care personnel communicate with one another?

Documentation reflects the quality of care and accountability in providing care.

Which of these is not a way that documentation is used?

What is the process of making entry on a client record called?

The traditional client record is organized by discipline.

What is the advantage of a source-oriented record?

Narrative-chronological notes are a traditional part of the source-oriented record.

Narrative-chronological notes are organized in chronological order.

There is a right or wrong order to the information in narrative-chronological notes.

What is a "problem-oriented medical record" (POMR) organized around?

POMR encourages collaboration and the problem list in the front of the chart alerts care givers of the client's needs?

A disadvantage of POMR is that caregivers differ in their ability to use the required charting format?

Another disadvantage of POMR is that it takes constant awareness to maintain an up-to-date problem list?

POMR is somewhat inefficient because assessments and interventions that apply to more than one problem must be repeated?

What are the four components of POMR?

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?

Problems in POMR are listed in order in which they are identified, redefined as patient condition changed or more data obtained?

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?

In POMR, the plan of care is listed under each problem in the progress note?

What are progress notes in POMR?

Progress notes in POMR are numbered to correspond to the problems on the problem list?

SOAP format is frequently used in progress notes?

What are the various formats used in progress notes?

What does "SOAP" stand for?

PIE groups information into three categories: Problem, Intervention, and Evaluation.

The problem statement, intervention, and evaluation in PIE are all numbered the same.

An advantage of PIE is that it eliminates traditional CP (care plans) and incorporates an ongoing care plan.

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?

Focus Charting is intended to make the client and client concerns and strengths the focus of care?

What are the three columns for recording in Focus Charting?

What may the "Focus" in Focus Charting be?

What does DAR stand for in Focus Charting?

The "Data" in DAR represents the assessment phase of care?

The "Action" in DAR represents planning and implementation of care?

The "Response" in DAR represents the evaluation phase?

Charting by Exception (CBE) is a documentation system where only abnormal or significant findings are recorded?

What are the three components of CBE?

An advantage of CBE is that it eliminates the need for lengthy, repetitive notes?

Another advantage of CBE is that it makes client changes in condition more obvious?

Computerized Documentation (Electronic Health Records) is used to store clients' databases, add data, create, and revise CPs, and document client progress?

Computerized Documentation makes care planning and documentation easy?

Computerized Documentation makes transmission of information from one care setting to another possible?

A disadvantage of Computerized Documentation is that client privacy may be infringed on if security measures are not used?

Computerized Documentation can cause breakdowns that make information temporarily unavailable?

A disadvantage of Computerized Documentation is that the system is expensive?

A disadvantage of Computerized Documentation is that training is required when a new or updated system is installed?

Case Management uses a multi-disciplinary approach to planning and documenting client care, using a critical pathway?

Case Management identifies the outcome expected to be achieved for certain groups of clients on each day of care?

Case Management uses critical pathways, graphics, and flow sheets.

Case Management promotes collaboration and teamwork among caregivers, helps decrease length of stay, and makes efficient use of time.

Case Management is best suited for patients with one or two diagnoses and few needs.

Clients with multiple diagnoses are difficult to document on a critical pathway.

Reporting is the purposeful communication of specific information to a person or group of people.

Reports should be concise and include pertinent information, excluding extraneous details.

What are the four types of reporting?

A Change of Shift Report is a report given to all nurses on the next shift.

The purpose of a Change of Shift Report is to provide continuity of care for patients.

A Change of Shift Report can be written or given orally.

A Change of Shift Report is sometimes given at the bedside, where the client and nurse participate in the information exchange?

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.

It's important to repeat information received in a telephone report back to the sender to ensure accuracy.

A telephone report should be concise and accurate, starting with the patient's name and relationship to the client.

A telephone report should include the patient's name, medical diagnosis, vital signs, and significant lab data.

When a nurse receives a telephone report, it's important to make the patient's record readily available for the physician.

After receiving a telephone report, the nurse should document the date and time and the content discussed during the call.

A physician who prescribes therapy over the phone is giving a "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).

The physician who gives a telephone order should sign it within 24 hours.

What information should be included when documenting a telephone order?

A Care Plan Conference is a meeting of a group of nurses to discuss possible solutions to certain problems of a client.

Nursing Rounds are a procedure in which two or more nurses visit selected clients at the bedside.

What are the objectives of Nursing Rounds?

What is the primary goal of documentation and reporting?