Documentation & Reporting (NUR 102)

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Questions and Answers

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 (A)</p> Signup and view all the answers

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

<p>Records (C)</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 (I)</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 (A), Problem Oriented Medical Records (POMR) (B), Problem, Intervention, Evaluation (PIE) (C), Focus Charting (D), Charting by Exception (CBE) (E)</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. (A)</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 (B)</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 (D)</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 (E)</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 (F)</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 (E)</p> Signup and view all the answers

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

<p>SOAPIE (B), SOAPIER (C), APIE (D), APIER (E)</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 (A)</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. (A)</p> Signup and view all the answers

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

<p>False (B)</p> Signup and view all the answers

What are the advantages of using the PIE system?

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

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

<p>All of the above (F)</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 (E)</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 (B)</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 (B)</p> Signup and view all the answers

What are the advantages of using Computerized Documentation?

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

What are the potential disadvantages of Computerized Documentation?

<p>All of the above (E)</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 (D)</p> Signup and view all the answers

What are the benefits of using Case Management?

<p>All of the above (D)</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 (B)</p> Signup and view all the answers

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

<p>True (A)</p> Signup and view all the answers

Which documentation activities are typically part of the nursing workflow?

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

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

<p>All of the above (N)</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 (A)</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 (A), Verification on each page of clinical records (B)</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 (B)</p> Signup and view all the answers

What are the different types of reports used in healthcare?

<p>All of the above (E)</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 (D)</p> Signup and view all the answers

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

<p>False (B)</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 (B)</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 (B)</p> Signup and view all the answers

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

<p>True (A)</p> Signup and view all the answers

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

<p>All of the above (E)</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 (B)</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 (E)</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 (B)</p> Signup and view all the answers

Flashcards

Client Record

A formal, legal document that records all client interactions and serves as evidence of care.

Problem-Oriented Medical Records (POMR)

A structured method of organizing client records around specific problems.

Discussion

An informal discussion between healthcare professionals to ID problems or develop strategies for resolving them.

Report

Oral, written, or computer-based communication used to convey information to others.

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Recording, Charting, or Documenting

The process of making entries on a client record.

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Source-Oriented Record

A traditional client record organized by discipline.

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Narrative Charting

A type of progress note used in narrative charting that includes routine care, normal findings, and client problems.

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DataBase (POMR)

A database that contains all information known about the client when they first enter the healthcare agency.

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Problem List (POMR)

A list of problems derived from the database, reflecting the patient's condition and updated as needed.

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Plan of Care (POMR)

A description of the plan of care generated for each active problem listed.

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Progress Notes (POMR)

Chart entries made by all healthcare professionals involved in a client's care, using the same format and numbered to correspond with the problem list.

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Problem, Intervention, Evaluation (PIE)

A method of charting that groups information into three categories: Problem, Intervention, and Evaluation.

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Focus Charting

A documentation system that focuses on the client and their strengths and concerns, using a DAR format for progress notes.

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Charting by Exception (CBE)

A documentation system where only abnormal or significant findings or exceptions to norms are recorded.

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Flow Sheets

A type of CBE record that visually tracks patient data over time.

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Computerized Documentation (EHRs)

A system of documentation that utilizes computerized methods to store client data, create care plans, and document progress.

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Case Management

A multidisciplinary approach to planning and documenting client care using critical pathways.

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Admission Nursing Assessment

A detailed assessment of the client upon admission to the healthcare facility.

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Nursing Care Plans

A written plan that outlines the nursing care specific to each client, updated as their condition changes.

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Kardex

A concise summary of a client's care needs, medications, and other vital information.

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Change of Shift Report

A type of report given to all nurses on the next shift to ensure continuity of care for patients.

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Telephone Report

A report given over the phone to convey important information to another healthcare professional.

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Care Plan Conference

A meeting of nurses to discuss possible solutions to patient problems.

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Nursing Round

When two or more nurses visit clients at the bedside to obtain information, discuss care, and evaluate nursing care received.

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Telephone Orders (TO)

Medication instructions given by a doctor over the phone.

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Correcting Errors in Charting

The act of correcting an error made in charting by drawing a single line through the mistake, writing "error" above it, dating and initialing the error.

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Documentation

A written record of all pertinent information related to a patient's care, including nursing notes, assessments, and plans.

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Reporting

To communicate specific information to a person or group of people in a concise and relevant manner.

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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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