Nursing Charting Techniques Overview

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Questions and Answers

What does WDL stand for in nursing documentation?

Within Differentiated Levels

Without Defined Limits

With Defined Limits

Within Defined Limits (correct)

What is Charting by Exception (CBE)?

The philosophy that the patient meets all standards unless otherwise documented.

The nurse writes a progress note when a patient's condition meets the standard normal criteria.

False

Telephone orders occur when a healthcare provider gives therapeutic orders over the ______ to a registered nurse.

phone Signup and view all the answers

What is the purpose of an incidence or occurrence report?

To document any event that is not considered a part of routine care. Signup and view all the answers

What is SBAR used for in nursing communication?

To share important patient information. Signup and view all the answers

Which of the following is NOT a common record-keeping form?

Medication Administration Record Signup and view all the answers

Nurses should include references to incident reports in the patient's medical record.

False Signup and view all the answers

What is the Nursing Process?

It is a systematic, assertive, problem-solving approach to identify and treat patient health issues. Signup and view all the answers

Which of the following phases are part of the Nursing Process? (Select all that apply)

Implementation Signup and view all the answers

What is the purpose of the assessment phase in the Nursing Process?

To collect data to establish the client’s baseline and response to health concerns. Signup and view all the answers

Define objective data in nursing assessment.

Objective data is measurable or observable information such as vital signs. Signup and view all the answers

What is subjective data?

Subjective data is information reported by the patient, such as statements about pain. Signup and view all the answers

What does the acronym SMART stand for in the context of care planning?

Specific, Measurable, Achievable, Relevant, Time-bound Signup and view all the answers

What defines a nursing diagnosis?

A nursing diagnosis is a judgement made after collecting and analyzing patient data. Signup and view all the answers

Differentiate between nursing diagnosis and medical diagnosis.

Nursing diagnosis is based on nursing judgment, while medical diagnosis is made by a physician. Signup and view all the answers

What does the term 'clinical judgment' refer to?

It refers to the nurse's ability to apply knowledge and experience to make informed decisions about patient care. Signup and view all the answers

What are the principles of critical thinking in nursing? (Select all that apply)

Creativity Signup and view all the answers

What are the three columns used in Focus Charting?

Data, Action, Response. Signup and view all the answers

What does POMR stand for?

Problem-Oriented Medical Record. Signup and view all the answers

The client's record is not considered a legal document.

False Signup and view all the answers

What is the significance of documentation in nursing?

Documentation provides a detailed account of the level and quality of care provided. Signup and view all the answers

What are the legal implications of poor documentation?

Poor documentation can compromise the entire client record. Signup and view all the answers

What should documentation be? (Select all that apply)

Timely and accurate Signup and view all the answers

Study Notes

What is the Nursing Process

Systematic, critical thinking framework used by nurses for patient care.
Involves problem-solving to identify and treat patient health issues.
Emphasizes individualized, client-centered care and collaboration with patients.

Phases of the Nursing Process

Assessment: Collect data to establish baseline and identify health concerns.
Diagnosis: Analyze collected data to identify strengths, problems, and nursing diagnoses.
Planning: Develop individualized care plans with SMART goals.
Implementation: Execute nursing interventions and document results.
Evaluation: Assess the effectiveness of interventions and modify care plans as needed.

Types of Data

Objective Data: Measurable information (e.g., BP 120/75).
Subjective Data: Patient-reported symptoms (e.g., "My pain is 10/10").
Primary Data: Information collected directly from the patient.
Secondary Data: Information from other sources (e.g., medical records, reports).

Data Collection & Validation

Importance of validating data for accurate analysis and interpretation.
Cues: Information through sensory observation (subjective or objective).
Inferences: Nurse's interpretation of cues (e.g., linking diaphoretic state to pain).

Concept Mapping

Visual tool to connect client issues and problems.
Enhances critical thinking and understanding in nursing assessments.

Nursing Diagnosis/Problem Statements

Derived from clinical reasoning and data analysis.
Nursing diagnoses can be classified as actual or risks, focusing on patient-centered concerns.

Writing a Nursing Diagnosis (NANDA Format)

P: Problem statement.
E: Etiology (causes of the problem).
S: Signs/symptoms.

Critical Thinking

Involves judgment and problem-solving in patient care.
Requires systematic, reflective, reasonable, and evidence-based decision-making.

Characteristics of a Critical Thinker

Curiosity: Desire to understand deeper concepts.
Systematic Thinking: Organized approach to problems.
Open-Mindedness: Willingness to consider alternatives.
Self-Confidence: Assurance in decision-making.
Truth-Seeking: Passion for knowledge and inquiry.

Clinical Judgment

Application of knowledge and experience to make informed decisions about patient care.
Involves synthesizing data from various sources to guide treatment plans.

Ways of Knowing in Nursing

Empirical: Objective knowledge based on evidence.
Aesthetic: Use of creativity and intuition in care.
Ethical: Guided by professional values and standards.
Personal: Knowledge from personal interactions and relationships.

Planning in the Nursing Process

Identify urgency and prioritize problems based on patient needs.
Use Maslow's hierarchy of needs for determining priorities.

Implementation

Execute the individualized care plan with appropriate interventions.
Assessment of patient culture, values, and goals is crucial during implementation.

Evaluation

Continuous assessment of the nursing process.
Collaborate with patients to evaluate the success of interventions.

Documentation

Crucial for documenting nursing care and patient progress.
Provides a legal record and ensures continuity of care.

Ethical and Legal Implications

Compliance with codes of ethics and guidelines for documentation.
Documentation serves as a legal record and can be used in future court cases.

Methods of Documentation

Various formats include narrative, problem-oriented, and focus charting.
Each method serves specific organizational and communication needs.

Incident Reporting

Documenting non-routine events such as adverse patient occurrences.
Objective descriptions aid in quality improvement without including them in patient records.

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Description

Explore various nursing charting methods, including their advantages and disadvantages. This quiz focuses on the principles of Charting by Exception (CBE) and how it impacts patient care documentation. Learn the nuances of effective nursing records management.