Nursing Chapter 16 Flashcards

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.

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.