Nursing Chapter 16 Flashcards
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Questions and Answers

What is Charting by Exception?

  • A reliable form of documentation, minimizing errors.
  • Increases the risk of liability in malpractice cases because 'not documented, not done.'
  • Can be used to document care accurately on stable patients. (correct)
  • Should be used only in ambulatory clinics and long-term care facilities.
  • When reviewing your documentation of a patient, it should reflect:

  • An objective, comprehensive, accurate account of patient data, nursing care provided, and patient response. (correct)
  • Everything that could have been done during your shift.
  • All the procedures, medications, and tasks that were done that day.
  • A detailed narrative account of what occurred moment by moment that shift.
  • Documentation of nursing care for home health patients requires which of the following? Choose all that are correct.

  • Use of the OASIS data set (correct)
  • Ongoing assessment of need for skilled nursing care (correct)
  • A weekly summary describing the patient's status and ongoing needs
  • Certification of homebound status (correct)
  • The use of abbreviations in healthcare reduces the risk for medical errors.

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

    List five components of nursing documentation that demonstrate quality care that is legally defensible.

    <p>Legibility, patient's name, information and date on each sheet, no blank spaces between entries, accurate and objective, errors lined out and initialed.</p> Signup and view all the answers

    Match the following definitions and terms:

    <p>A. Information received on the status of a group of individual patients = 4. Change-of-shift report B. Initiated at time of admission and completed at discharge = 5. Discharge summary C. Documents routine, one-time and PRN medications = 1. Medication administration record D. Progress note that reflects only one health focus = 2. SOAP/PIE E. Assessment data, interventions, and patient responses written in a detailed chronological manner = 3. Narrative charting</p> Signup and view all the answers

    What are important factors to document when taking a physician's verbal order?

    <p>Document the date and time, repeat the prescription, spell unfamiliar names, verify accuracy with a second nurse if possible, and ensure the physician's countersignature within 24 hours.</p> Signup and view all the answers

    Study Notes

    Charting by Exception

    • A reliable method for documenting care in stable patients, streamlining nursing documentation.
    • Integrates with flowsheets and brief narrative charting for thoroughness.
    • Reduces documentation of routine information, but must still include both routine and variant findings.

    Accurate Documentation

    • Documentation must be objective, comprehensive, and accurately reflect patient data, care provided, and patient responses.
    • Focus on assessment data, interventions, and evaluations rather than including unnecessary details.

    Home Health Documentation Requirements

    • Requires evidence of homebound status, use of the OASIS data set, and ongoing need for skilled nursing care.
    • Monthly summaries of patient status and needs are mandatory, not weekly.

    Abbreviations in Healthcare

    • Use of abbreviations increases risk for medical errors, as noted by JCAHO National Patient Safety Goals.
    • Certain abbreviations such as "u," "iu," "qd," and "qod" are discouraged due to frequent transcription errors.

    Components of Quality Nursing Documentation

    • Includes legibility, patient's name and date on each page, no blank spaces, accurate objectivity, signature and title of the provider, and documenting errors appropriately.

    Definitions and Terms Matching

    • Group status update: Change-of-shift report.
    • Admission initiation and discharge completion: Discharge summary.
    • Medication administration: Medication administration record.
    • Focused progress note: SOAP/PIE.
    • Detailed chronological assessment: Narrative charting.

    Documenting Verbal Orders

    • Write prescriptions only if directly heard; verify understanding by repeating the order.
    • Use correct methods for communication clarity (spelling names, pronouncing digits).
    • Document date, time, and details accurately, including provider's name following "T.O."
    • Ensure physicians counter-sign verbal orders within 24 hours.

    Incident Reporting

    • Occurrence reports are necessary for lost personal items, such as dentures.
    • Administering medications within 30 minutes of scheduled time does not require a report.

    Source-Oriented Charting

    • Organizes documentation according to the discipline involved, separating records by each department rather than focusing on patient problems.

    Acceptable Medical Abbreviations

    • "NKA" (No Known Allergies) is the appropriate abbreviation for documenting a patient with no allergies.

    Nursing Assessment Flow Sheets

    • Comprehensive forms that incorporate assessments and nursing actions organized by body systems.

    Late Entry Documentation

    • If documentation is missed, a late entry should be made as an addition to narrative notes; creating a late entry maintains legal documentation integrity.

    Electronic Health Record (EHR) Benefits

    • EHR systems enhance interdisciplinary collaboration and improve efficiency in patient care procedures.
    • They also assist in tracking medication administration and usage over time.

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    Description

    Test your knowledge with these flashcards from Chapter 16 of nursing. Focus on the concept of charting by exception and its implications for patient care documentation. This chapter highlights the importance of accurate documentation in nursing practice.

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