Podcast
Questions and Answers
What is one of the essential purposes of accurate and comprehensive recording in patient documentation?
What is one of the essential purposes of accurate and comprehensive recording in patient documentation?
- To support investigations such as legal inquiries (correct)
- To create a casual record of patient visits
- To restrict access to patient information
- To provide entertainment for the medical staff
Only certain categories of nurses are responsible for recording nursing interventions.
Only certain categories of nurses are responsible for recording nursing interventions.
False (B)
What must be recorded in patient documentation regarding any abnormalities?
What must be recorded in patient documentation regarding any abnormalities?
The specific abnormality, the person whom it was reported to, and relevant nursing interventions.
All patient documentation must reflect a complete picture of the entire period of __________ in a legal and valid manner.
All patient documentation must reflect a complete picture of the entire period of __________ in a legal and valid manner.
Match the following elements of nursing documentation with their descriptions:
Match the following elements of nursing documentation with their descriptions:
Which option is NOT a recommended practice for patient documentation?
Which option is NOT a recommended practice for patient documentation?
Patient documentation is only important for billing purposes.
Patient documentation is only important for billing purposes.
What must nursing practitioners comply with regarding clinical records?
What must nursing practitioners comply with regarding clinical records?
What is NOT considered a diagnosis according to the admission criteria?
What is NOT considered a diagnosis according to the admission criteria?
A full signature and personnel number are required on the Signature Sheet.
A full signature and personnel number are required on the Signature Sheet.
What types of history should be collected during the clinical assessment?
What types of history should be collected during the clinical assessment?
The four physical examination techniques include inspection, percussion, palpation, and ______.
The four physical examination techniques include inspection, percussion, palpation, and ______.
Match the following types of history with their descriptions:
Match the following types of history with their descriptions:
Which of the following is considered objective data during a clinical assessment?
Which of the following is considered objective data during a clinical assessment?
A clinical assessment can take place immediately upon patient admission.
A clinical assessment can take place immediately upon patient admission.
During the clinical assessment, using all ______ is essential for a thorough examination.
During the clinical assessment, using all ______ is essential for a thorough examination.
What does systolic pressure indicate?
What does systolic pressure indicate?
A normal adult pulse rate is considered to be between 80 to 120 beats per minute.
A normal adult pulse rate is considered to be between 80 to 120 beats per minute.
What happens to the pulse when it is palpated?
What happens to the pulse when it is palpated?
Reasons for ______ include inflammatory response and sepsis.
Reasons for ______ include inflammatory response and sepsis.
Which of the following is NOT a reason for hypothermia?
Which of the following is NOT a reason for hypothermia?
Match the following vital sign measurements with their descriptions:
Match the following vital sign measurements with their descriptions:
It is necessary to write down the actual values for vital sign measurements.
It is necessary to write down the actual values for vital sign measurements.
What should be assumed if pain is new or cannot be relieved with normal analgesia?
What should be assumed if pain is new or cannot be relieved with normal analgesia?
What does the 'R' in SMART principles stand for?
What does the 'R' in SMART principles stand for?
Nursing prescriptions should be vague and open-ended.
Nursing prescriptions should be vague and open-ended.
What is the primary role of a nurse when supporting patients and their families emotionally?
What is the primary role of a nurse when supporting patients and their families emotionally?
A patient care plan provides written, detailed instructions on activities nurses should implement to help a patient reach expected __________.
A patient care plan provides written, detailed instructions on activities nurses should implement to help a patient reach expected __________.
Match the following components of nursing prescriptions with their correct descriptions:
Match the following components of nursing prescriptions with their correct descriptions:
Which of the following is an example of a SMART nursing prescription?
Which of the following is an example of a SMART nursing prescription?
A nursing prescription is activated with a checkmark and deactivated with a line drawn through it.
A nursing prescription is activated with a checkmark and deactivated with a line drawn through it.
What should be documented by the nurse who completes the basic needs care plan?
What should be documented by the nurse who completes the basic needs care plan?
Which of the following is NOT included in the definition of output?
Which of the following is NOT included in the definition of output?
A patient sticker should be placed in the space provided to identify the document.
A patient sticker should be placed in the space provided to identify the document.
What should be recorded if a patient has no known allergies?
What should be recorded if a patient has no known allergies?
The totals for ______ and the totals for ______ should be added to determine fluid balance.
The totals for ______ and the totals for ______ should be added to determine fluid balance.
What must be completed before the patient receives any pre-medication?
What must be completed before the patient receives any pre-medication?
Match the documentation requirements with their correct descriptions:
Match the documentation requirements with their correct descriptions:
The nurse is responsible for writing what the patient consented to and what procedure is stated in the theatre list.
The nurse is responsible for writing what the patient consented to and what procedure is stated in the theatre list.
What is used to record different types of output, such as urine or vomitus?
What is used to record different types of output, such as urine or vomitus?
What should be added to individualize the care plan for potential urinary retention?
What should be added to individualize the care plan for potential urinary retention?
Nursing prescriptions do not need to be initialed if they are ticked or activated.
Nursing prescriptions do not need to be initialed if they are ticked or activated.
What should be done to ensure patient comfort regarding positioning?
What should be done to ensure patient comfort regarding positioning?
The expected outcome for urinary output should be a minimum of _____ ml/hour.
The expected outcome for urinary output should be a minimum of _____ ml/hour.
Match the potential complications with the appropriate nursing actions:
Match the potential complications with the appropriate nursing actions:
Which of the following is NOT a component of the nursing documentation guidelines?
Which of the following is NOT a component of the nursing documentation guidelines?
Recording the volume of emptied urinary catheter on the fluid balance record is unnecessary.
Recording the volume of emptied urinary catheter on the fluid balance record is unnecessary.
What should be added to nursing prescriptions related to potential phlebitis or infiltration?
What should be added to nursing prescriptions related to potential phlebitis or infiltration?
Flashcards
Purpose of patient documentation
Purpose of patient documentation
To accurately and comprehensively record patient condition, treatment, care, reactions, and communication with other healthcare professionals.
Effective Communication
Effective Communication
Accurate and consistent documentation facilitates smooth information sharing among the healthcare team.
Legal and Billing
Legal and Billing
Correct records support investigations, legal cases, complaints, medical aid authorizations, and billing.
Clinical Coding Impact
Clinical Coding Impact
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Nursing Documentation Responsibilities
Nursing Documentation Responsibilities
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Record Format Restrictions
Record Format Restrictions
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Abnormality Reporting
Abnormality Reporting
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Complete Hospitalization Record
Complete Hospitalization Record
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Blood Pressure
Blood Pressure
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Systolic Pressure
Systolic Pressure
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Diastolic Pressure
Diastolic Pressure
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Normal Adult Pulse Rate
Normal Adult Pulse Rate
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Pulse Measurement
Pulse Measurement
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Pain
Pain
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Pyrexia
Pyrexia
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Hypothermia
Hypothermia
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Admission Diagnosis
Admission Diagnosis
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Clinical Assessment
Clinical Assessment
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Current Complaint
Current Complaint
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Patient History
Patient History
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Objective Data
Objective Data
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Subjective Data
Subjective Data
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Physical Examination
Physical Examination
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Procedure vs. Diagnosis
Procedure vs. Diagnosis
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What does a care plan provide?
What does a care plan provide?
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What is a nursing prescription?
What is a nursing prescription?
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SMART principles
SMART principles
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Who creates the initial care plan?
Who creates the initial care plan?
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Can RN/PN/GN change the care plan?
Can RN/PN/GN change the care plan?
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How do you activate/deactivate a prescription?
How do you activate/deactivate a prescription?
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Why support patients emotionally?
Why support patients emotionally?
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Why support families emotionally?
Why support families emotionally?
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Potential Wound Infection Documentation
Potential Wound Infection Documentation
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Potential Urinary Infection Documentation
Potential Urinary Infection Documentation
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Potential Urinary Retention Documentation
Potential Urinary Retention Documentation
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Potential Phlebitis/Infiltration Documentation
Potential Phlebitis/Infiltration Documentation
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Potential Respiratory Complications Documentation
Potential Respiratory Complications Documentation
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Potential Nausea Documentation
Potential Nausea Documentation
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Potential Circulatory Deficiency Documentation
Potential Circulatory Deficiency Documentation
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Initialing Nursing Prescriptions
Initialing Nursing Prescriptions
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What are the main types of output?
What are the main types of output?
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How to record output
How to record output
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Fluid balance
Fluid balance
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Consent confirmation
Consent confirmation
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Pre-medication Consent
Pre-medication Consent
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Peri-Operative Record
Peri-Operative Record
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Recording Allergies
Recording Allergies
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Patient Sticker
Patient Sticker
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Study Notes
Guideline to the Completion of Patient Documentation
- This document guides users in completing adult patient nursing and clinical records, ensuring consistent and accurate completion in all clinical facilities.
- Accurate and comprehensive recording is crucial for: describing patient condition, treatment plan, interventions, and patient responses; ensuring effective communication among care team members; supporting investigations, legal issues, and complaints; informing medical aid authorizations and billing; and providing data for clinical coding, statistics, funding, and strategic decisions.
- This policy applies to nursing practitioners and users recording information in adult patient records.
Table of Contents
- The document includes a detailed table of contents listing various sections related to completing patient documentation for adult patients in several clinical settings.
- Specific record types such as the General Assessment Record (N0953), Waterlow Pressure Sore Risk Assessment (N3297), Venous Thrombo-Embolism (VTE) Risk Assessment (N3297), are highlighted with corresponding page numbers, indicating the different sections of the document.
General Information
- This section outlines the purpose of patient documentation, emphasizing its role in accurate and consistent record-keeping in all clinical settings. This document is a comprehensive guideline, used to ensure the correct method of keeping patient information.
- The document encompasses the legal and clinical requirements that govern record keeping.
- Essential elements of quality include patient responses to nursing care and treatment, and multidisciplinary team communication.
- Mediclinic approved patient records are specified, with details about not using ticks or crosses to indicate choices in assessment documents and what information should be avoided.
Critical Elements in Documentation
- The document covers key terms in patient documentation, including legibility, accuracy, conciseness, credibility, and chronological order.
- It emphasizes the importance of clear, permanent records, free from errors.
- Documentation must accurately reflect nursing care rendered, patient responses to care and treatment, and communication with the multidisciplinary team.
- This must be presented in a patient-centered, logical, and sequential manner, contemporaneously or as events happen.
- Details regarding the formatting, and completion of specific sections of the document are provided.
Completion: General Assessment Record (N0953)
- Information on how patients are welcomed and oriented is presented in the section relating to general patient assessment forms.
- The section explains that the record is divided into sections and used for both admission centers and direct admissions in a nursing unit.
- Recording patient-related information on these forms is essential.
Completion: Waterlow Pressure Sore Risk Assessment (N3297)
- The document details using a form to assess patient risk for developing pressure sores.
- Records the date and time of the assessment.
- This information is to help determine if patients need additional care measures.
Completion: Venous Thrombo-Embolism (VTE) Risk Assessment (N3297)
- This section provides details on assessing a patient's risk of developing a thrombosis.
- Guidelines for recording date, time and criteria with scores are included.
Completion: Signature Sheet (N3373)
- This form ensures all members of the multidisciplinary team who record patient information sign the sheet.
- Record relevant details such as employee/agency number, initials and surname.
Completion: Adult Early Warning Observation Record (N3182)
- The document outlines the use of a record for identifying patients at risk of deterioration.
- Also provides direction for nurse practitioners on appropriate interventions and documentation.
- The record should include the time of observations and any related nursing interventions.
Completion: Patient Care Plan Basic Needs (N0909)
- Describes the use of basic care plan for patients to document their hygiene needs.
- Outlines activation and deactivation of nursing prescriptions and necessary details.
Completion: Specific Patient Care Plan (N1012)
- This section details the inclusion of SMART principles in nursing prescriptions.
- Explicit examples of specific, measurable, attainable, realistic, and time-bound prescriptions are demonstrated.
Completion: Fluid Balance Record (N0949)
- This explains the importance of documenting fluid intake and output, a critical measure for patient wellbeing.
- This includes details of recording and documenting times of intake and output.
Completion: Peri-Operative Record (N0997)
- This form focuses on pre-operative consent for patient procedures/surgeries
- Details on recording allergies, patient consent with the procedure, and recording risk factors.
- Includes essential details for pre-op preparations like documenting the consent to participate in the procedure or the filming for training purposes.
Completion: Post-Operative Patient Care Plan (N1000)
- This section details the post-operative care plan, focusing on recording vital signs, intake/output, level of consciousness, and pain management.
- Essential parameters to track the overall condition of the patient.
Completion: Implementation Record (N1009)
- This record focuses on documenting all care activities performed for patients.
- Timing, actions, observations, potential problems, and abnormalities should be recorded in detail.
Completion: Prescription Chart (P1002)
- Explain steps for completing prescription charts with patient allergies, weight, height, medical condition, and ward/bed information to be recorded.
Completion: Pharmacy Order Form
- This section deals with medication ordering for the pharmacy. This includes details like the date, time, medication name, amount, initial and signature of the employee in charge.
Completion: Prescription Booklet (P3246)
- This section details recording patient medication specifics, including allergies, risk factors, weight, height/BMI, ward/bed number, and date commencing.
Completion: Clinical Evaluation: General Patients (CL3187)
- The document is used to share patient care details with case managers for accurate claims and payments.
- Shows a method of recording vital signs and other important patient information.
History and Version Control
- Details about the versions, effective dates, authors, and updates to ensure the policy remains current and applicable.
Responsibilities
- The document outlines specific responsibilities for unit managers, nurses, clinical facilitators, and learning/development facilitators in maintaining accurate documentation procedures.
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Description
Test your knowledge on the essential aspects of nursing documentation. This quiz covers recording practices, required entries, and the legal implications of patient documentation. Understand the importance of accurate records in ensuring quality care and compliance.
