Documentation & Reporting (NUR 102)
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What is the main idea behind the statement: "If documentation is not charted, it wasn't done!"

It is important to document all actions and interventions provided to a patient. If it's not documented, it's not considered to have been done.

What is the definition of Documentation in healthcare?

The written or printed legal record of all pertinent interactions with the client.

Which methods are utilized by healthcare professionals to communicate with each other?

  • Discussions
  • Reports
  • Records (chart or client record)
  • All of the above (correct)

    • What types of communication are considered 'informal' when it comes to documentation?

    <p>Discussions</p> Signup and view all the answers

    What type of documentation is considered a 'formal, legal document'?

    <p>Records</p> Signup and view all the answers

    What is defined as 'the process of making entry on a client record'?

    <p>Recording, charting, or documenting</p> Signup and view all the answers

    What are the main purposes of documentation in healthcare?

    <p>All of the above</p> Signup and view all the answers

    What is the purpose of legal documentation in healthcare?

    <p>It is used in court as evidence.</p> Signup and view all the answers

    What is the importance of accurate documentation for reimbursement purposes?

    <p>The client's record must contain the correct diagnosis-related group codes and reveal that the appropriate care has been given.</p> Signup and view all the answers

    What is the main purpose of 'Health care analysis' in relation to documentation?

    <p>To identify health care agency needs and services that cost money and those that generate revenue.</p> Signup and view all the answers

    Which of the following are considered traditional documentation systems?

    <p>Source Oriented Record</p> Signup and view all the answers

    What is the main characteristic of the Source Oriented Record system?

    <p>The traditional client record and organized by discipline.</p> Signup and view all the answers

    What are the advantages of using a Source Oriented Record system?

    <p>It is easy to locate discipline-specific information.</p> Signup and view all the answers

    What kind of information is included in a Source Oriented Record's narrative charting?

    <p>Consists of written notes that include routine care, normal findings, and client problems.</p> Signup and view all the answers

    In narrative charting, there is a strict right or wrong order to how the information is documented.

    <p>False</p> Signup and view all the answers

    What is the main principle behind the Problem Oriented Medical Records (POMR) system?

    <p>Is documentation organized around client problems rather than the source of information, all disciplines record on the same form.</p> Signup and view all the answers

    What are the advantages of using the Problem Oriented Medical Records (POMR) system?

    <p>All of the above</p> Signup and view all the answers

    What are the four components of the Problem Oriented Medical Records (POMR) system?

    <p>All of the above</p> Signup and view all the answers

    What information is contained in the 'Data base' component of the POMR system?

    <p>Contains all information known about the client when the client first enters the health care agency, updated according to change in health status.</p> Signup and view all the answers

    How is the 'Problem list' component of the POMR system derived?

    <p>Derived from the data base; problems are listed in order in which they are identified, redefined as patient condition changed or more data obtained</p> Signup and view all the answers

    How is the 'Plan of care' component of the POMR system developed?

    <p>Made with reference to active problem list, it is generated by the person who lists the problem, listed under each problem in progress note.</p> Signup and view all the answers

    Who are the individuals responsible for recording 'Progress notes' within the POMR system?

    <p>Is a continuous entry made by all health professionals involved in a client's care</p> Signup and view all the answers

    What are the different types of charting formats commonly used within the POMR system?

    <p>All of the above</p> Signup and view all the answers

    Which of the following information is typically included in a SOAP charting format?

    <p>All of the above</p> Signup and view all the answers

    Which of the following charting formats includes an 'Evaluation' component?

    <p>SOAPIE</p> Signup and view all the answers

    What is the main idea behind the 'Problem, Intervention, Evaluation (PIE)' system of documentation?

    <p>It groups information into three categories: Problem, Intervention, and Evaluation.</p> Signup and view all the answers

    The PIE system primarily uses flow sheets for assessments and progress notes for interventions.

    <p>True</p> Signup and view all the answers

    What is the significance of NANDA in the PIE system?

    <p>NANDA is used to define the problem.</p> Signup and view all the answers

    In the PIE system, problem statements, interventions, and evaluations are all numbered differently.

    <p>False</p> Signup and view all the answers

    What are the advantages of using the PIE system?

    <p>All of the above</p> Signup and view all the answers

    What is the central focus of the Focus Charting system?

    <p>It is intended to make the client and client concerns and strengths the focus of care.</p> Signup and view all the answers

    What are the three columns typically used in Focus Charting?

    <p>All of the above</p> Signup and view all the answers

    What can be considered a 'Focus' in Focus Charting?

    <p>All of the above</p> Signup and view all the answers

    How are the progress notes organized in Focus Charting?

    <p>The progress notes are organized into DAR: Data, Action, Response.</p> Signup and view all the answers

    What does documenting 'Data' involve in the DAR format?

    <p>Assessment phase</p> Signup and view all the answers

    What does documenting 'Response' involve in the DAR format?

    <p>Evaluation phase</p> Signup and view all the answers

    What is the main idea behind the 'Charting by Exception (CBE)' system?

    <p>It is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded.</p> Signup and view all the answers

    What are the various elements commonly included in CBE flow sheets?

    <p>All of the above</p> Signup and view all the answers

    How does the 'Standards of nursing care' approach in CBE streamline documentation?

    <p>It eliminates much of the repetitive charting of routine care. Usually, documentation only involves a check mark in the routine standards box on the graphic record.</p> Signup and view all the answers

    Describe the concept of 'Bedside access to chart form' in the CBE system.

    <p>All flow sheets are kept at the client's bedside to allow immediate recording and to eliminate the need to transcribe data from the nurse's worksheet to the permanent record.</p> Signup and view all the answers

    What is the main purpose behind 'Computerized Documentation' or 'Electronic Health Records (EHRs)'?

    <p>Used to store client databases, add data, create and revise CP, and document client progress</p> Signup and view all the answers

    EHRs are designed to make care planning and documentation more difficult.

    <p>False</p> Signup and view all the answers

    EHRs can only be used within one specific care setting, limiting their functionality for sharing information.

    <p>False</p> Signup and view all the answers

    What are the advantages of using Computerized Documentation?

    <p>All of the above</p> Signup and view all the answers

    What are the potential disadvantages of Computerized Documentation?

    <p>All of the above</p> Signup and view all the answers

    What is the approach utilized in 'Case Management' for planning and documentation?

    <p>Uses a multidisciplinary approach to planning and documenting client care, using critical pathways.</p> Signup and view all the answers

    What is the main goal of Case Management in relation to patient care?

    <p>Identify the outcome that certain groups of clients are expected to achieve on each day of care.</p> Signup and view all the answers

    Which tools are commonly used within Case Management?

    <p>All of the above</p> Signup and view all the answers

    What are the benefits of using Case Management?

    <p>All of the above</p> Signup and view all the answers

    Case Management is equally effective for clients with multiple diagnoses and those with just one or two diagnoses.

    <p>False</p> Signup and view all the answers

    Documenting on the critical pathway is challenging for clients with multiple diagnoses.

    <p>True</p> Signup and view all the answers

    Which documentation activities are typically part of the nursing workflow?

    <p>All of the above</p> Signup and view all the answers

    Which of the following guidelines are essential for recording information accurately?

    <p>All of the above</p> Signup and view all the answers

    Which of the following aspects is critical for ensuring the permanence of patient records?

    <p>Using dark ink</p> Signup and view all the answers

    Which of the following elements are crucial for ensuring the accuracy of a patient's name in documentation?

    <p>Correct spelling</p> Signup and view all the answers

    What are the correct steps involved in correcting errors in charting?

    <p>Draw a single line through the error, write 'error' above the entry, and date, time, and initial the 'errored' entry.</p> Signup and view all the answers

    What is the purpose of reporting information in healthcare?

    <p>To communicate specific information to a person or group of people.</p> Signup and view all the answers

    Reports should be detailed and elaborate, ensuring comprehensive information is conveyed.

    <p>False</p> Signup and view all the answers

    What are the different types of reports used in healthcare?

    <p>All of the above</p> Signup and view all the answers

    What is the purpose of a change of shift report?

    <p>To provide continuity of care for the patient.</p> Signup and view all the answers

    How can a change of shift report be delivered?

    <p>All of the above</p> Signup and view all the answers

    Change of shift reports are always delivered in a private setting, ensuring confidentiality.

    <p>False</p> Signup and view all the answers

    What is the main purpose of a telephone report in healthcare?

    <p>To provide essential information over the phone.</p> Signup and view all the answers

    What information should be included in a telephone report?

    <p>Include the date and time, the name of the person providing the information, the subject of the information, and a signature.</p> Signup and view all the answers

    It is not necessary to repeat the information back to the caller during a telephone report.

    <p>False</p> Signup and view all the answers

    A telephone report should be as detailed as possible, covering all aspects of the patient's care.

    <p>False</p> Signup and view all the answers

    A telephone report should include the patient's name and their relationship to the caller.

    <p>True</p> Signup and view all the answers

    What kind of information is typically conveyed during a telephone report?

    <p>All of the above</p> Signup and view all the answers

    The nurse receiving the phone report can rely solely on the phone call for information and should not refer to the patient's record for context.

    <p>False</p> Signup and view all the answers

    What information should be documented after a telephone report?

    <p>Document the date and time, and the call content.</p> Signup and view all the answers

    What are 'Telephone Orders (TO)' in healthcare?

    <p>When a physician prescribes therapy over the phone to a registered nurse.</p> Signup and view all the answers

    How are telephone orders documented?

    <p>Transcribe them to the physician order sheet, indicating it as a verbal order (VO) or a telephone order (TO).</p> Signup and view all the answers

    Who should sign a telephone order?

    <p>Physician</p> Signup and view all the answers

    What information must be included when documenting a telephone order?

    <p>All of the above</p> Signup and view all the answers

    What is the purpose of a 'Care Plan Conference' in healthcare?

    <p>A meeting of a group of nurses to discuss possible solutions to certain problems of a client.</p> Signup and view all the answers

    What is the main purpose of 'Nursing Rounds'?

    <p>A procedure in which two or more nurses visit selected clients at bedside to obtain information that helps in developing nursing care plans, provide an opportunity for the client to discuss their care, and evaluate the nursing care received.</p> Signup and view all the answers

    Nursing rounds are solely focused on evaluating the nursing care received by the patient.

    <p>False</p> Signup and view all the answers

    Study Notes

    Documentation & Reporting (NUR 102)

    • Documentation is the written or printed legal record of interactions with a client. This reflects the quality of care and accountability.
    • If documentation is not charted, it wasn't done.
    • Health professionals communicate through discussion, reports, and records.
    • Documentation systems include source-oriented record, problem-oriented medical records (POMR), problem, intervention, evaluation (PIE), charting by exception (CBE), computerized documentation, and case management.
    • A source-oriented record is organized by discipline, with each person or department having their own section in the patient's chart; this method is easy to locate discipline-specific information but can be difficult to track client problems.
    • POMR documents are organized around client problems, not disciplines.
    • Advantages of POMR include encouraging collaboration and alerting caregivers to client needs. Disadvantages include differences in caregiver skills and difficulties maintaining an updated problem list.
    • POMR consists of database, problem list, care plan, and progress notes (often using SOAP/SOAPIE/SOAPIER/APIE/APIER format).
    • PIE groups information into three categories: problem, intervention, and evaluation. NANDA terminology is used for the problem statement, intervention, and evaluation, which are numbered the same. It eliminates traditional charting and incorporates an ongoing care plan.
    • Focus charting organizes progress notes into data, action, and response (DAR) categories, focusing on client needs and strengths.
    • Charting by exception (CBE) only records abnormal or significant findings or exceptions to norms. Flow sheets and standards of nursing care are used.
    • Advantages of CBE is the reduction in lengthy repetitive notes, and makes changes in client condition clearer.
    • Computerized documentation is used to store client information, create and revise care plans, and document progress, making care planning and documentation much easier.
    • Computerized documentation (Electronic Health Records) allows for more efficient use of time, focus on client outcomes, and immediate order checks before treatment administration. Disadvantage of this system may be client's privacy infringements if security measures are not used. The system can be expensive and require a training period for new systems.
    • Case management uses a multidisciplinary approach utilizing critical pathways, graphics, and flow sheets with the aim of creating efficiency and decreasing the length of stay. This approach is challenging for care of client with multiple diagnoses.
    • Documentation activities include admission assessment, nursing care plans, Kardex, flow sheets, progress notes, and nursing discharge/referral.
    • General guidelines for recording include considerations for date, time, clarity/legibility, permanence, accepted terminology, accuracy, sequence, completeness, conciseness, and legal prudence (appropriate for the situation).
    • Principles for correcting errors in charting involve single-line through errors, writing "error" above the entry, and dating, timing, and initialing the corrected entry.

    Reporting

    • Reporting communicates specific information to a person or groups of people. This is concise, using pertinent information, without extraneous details.
    • Reporting includes methods such as change of shift, telephone reports, care plan conferences, and nursing rounds.
    • A change of shift report is given by the outgoing shift to the next shift.
    • A telephone report is when someone communicates their findings to a physician by phone that should be documented on that same day as well. Telephone reports are often concise, including patient name, medical diagnosis, vital signs, significant lab results, and any additional pertinent medical information.
    • Care plan conferences are facilitated meetings of nurses to brainstorm possible solutions for a client's problems.
    • Nursing rounds are when nurses visit patient's bedside for the purpose of obtaining information for care plans, for the patient to better express their needs, and to evaluate their obtained care treatment.

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    Description

    Explore the essential aspects of documentation in nursing with this quiz for NUR 102. Understand various documentation systems and their relevance in ensuring quality care and accountability. Test your knowledge on the differences between source-oriented and problem-oriented medical records, and learn the advantages and disadvantages of these approaches.

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