Podcast
Questions and Answers
What is one of the purposes of documentation in healthcare?
What is one of the purposes of documentation in healthcare?
- To bill insurance companies
- To communicate with the care team
- To educate patients
- All of the above (correct)
Illegible writing can cause harm to patients due to wrong treatment or lack of treatment.
Illegible writing can cause harm to patients due to wrong treatment or lack of treatment.
True (A)
What is the purpose of the Admission History and Assessment document?
What is the purpose of the Admission History and Assessment document?
To provide information on the client's previous state prior to hospitalization and what brought them to seek medical care.
The _______________________ document provides instruction and education on care, medications, and follow-up appointments.
The _______________________ document provides instruction and education on care, medications, and follow-up appointments.
What principle of data entry ensures that the source of the finding is identified?
What principle of data entry ensures that the source of the finding is identified?
Nursing Care Plans are created at discharge.
Nursing Care Plans are created at discharge.
Match the following documents with their descriptions:
Match the following documents with their descriptions:
The principle of data entry that ensures the writing is clear and easily read by others is called _______________________.
The principle of data entry that ensures the writing is clear and easily read by others is called _______________________.
What is the purpose of software documentation?
What is the purpose of software documentation?
Software documentation is not an important part of a software project.
Software documentation is not an important part of a software project.
What is one benefit of creating software documentation?
What is one benefit of creating software documentation?
Software documentation can help developers and other technical stakeholders understand the technical aspects of the software, leading to ______________ collaboration.
Software documentation can help developers and other technical stakeholders understand the technical aspects of the software, leading to ______________ collaboration.
What is one of the principles of data entry?
What is one of the principles of data entry?
Match the following principles of data entry with their descriptions:
Match the following principles of data entry with their descriptions:
Software documentation is only useful for users.
Software documentation is only useful for users.
What is one common document used by nurses?
What is one common document used by nurses?
What is the purpose of an Incident Report?
What is the purpose of an Incident Report?
Clinical Pathways are used to give end of shift reports.
Clinical Pathways are used to give end of shift reports.
What does SBAR stand for?
What does SBAR stand for?
Nursing Progress Notes are recorded on all clients but performed differently depending on the ______________________.
Nursing Progress Notes are recorded on all clients but performed differently depending on the ______________________.
Match the types of nursing notes with their descriptions:
Match the types of nursing notes with their descriptions:
Acuity charting is used to determine the number of nursing hours required for a patient.
Acuity charting is used to determine the number of nursing hours required for a patient.
Study Notes
Software Documentation
- Definition: Provides information about software products and systems
- Importance: Provides clear, consistent, and up-to-date information, increases efficiency, and enhances collaboration among team members
Benefits of Creating Software Documentation
- Increased efficiency: Quick access to information reduces time spent on finding it
- Enhanced collaboration: Ensures everyone is working towards the same goals
Principles of Data Entry
- Accurate: Write only observations seen, heard, smelled, or felt, and use numbers instead of subjective words
- Complete: Include all data and information, such as nursing interventions, medication, and client teaching
- Concise: Use approved abbreviations and brief entries
- Timelines: Document care, treatments, and procedures as soon as possible
- Objective: Identify the source of the finding
- Legible: Writing must be clear and easily readable
- Organization: Entry must show a logical and systematic grouping of information using the nursing process
Purpose of Documentation
- Communication: Gives a clear picture of what took place in a shift
- Assessment: Alerts care team of changes in status from one shift to the next
- Care planning: Care planning comes from assessment of objective and subjective data
- Quality assurance: Ensures standards are met
- Payment: Insurance only pays for certain care, diagnosis, and must be documented
- Legal documentation: Protects against legal disputes
- Research: Charts can be reviewed for trends and patient outcomes
- Education: Can be used to teach patients
Common Documents Used by Nurses
- Admission History and Assessment: Provides information on the client's previous state and reasons for seeking medical care
- Discharge Form: Instructions and education on care, medications, and when to see the physician
- Nursing Care Plans: Plan of care started on admission with nursing diagnosis, outcomes towards discharge
- Flow Sheets/Graphic Sheets: Allows documentation of assessment findings and routine care activities
- Kardex: Patient care record updated each shift, includes IV fluids, treatments, and therapies
- Clinical Pathways: Include key interventions to standardize care and improve patient outcomes
- Medication Administration Records (MAR): Where medications given are documented
- Nursing Progress Notes: Recorded on all clients, but performed differently depending on the institution
- Acuity Charting: Assigns a number to procedures and care to determine nursing hours required for a patient
- Incident Report: Documents errors and finds ways to prevent them
Ways of Documentation
- SBAR (Situation, Background, Assessment, Recommendation/Request): A framework for communication that provides structured and orderly approach
- Types of nursing notes: Narrative, SOAP, PIE, and SOAPIER
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Description
This quiz covers the importance of software documentation in nursing informatics, including its benefits, principles, and purpose. It also explores common documents used by nurses in software documentation.
