Nursing Informatics: Software Documentation

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Questions and Answers

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.

True (A)

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.

Discharge Form Signup and view all the answers

What principle of data entry ensures that the source of the finding is identified?

Objectivity (C) Signup and view all the answers

Nursing Care Plans are created at discharge.

False (B) Signup and view all the answers

Match the following documents with their descriptions:

Admission History and Assessment = Provides information on the client's previous state prior to hospitalization. Discharge Form = Plan of care started on admission with nursing diagnosis, outcomes toward discharge. Nursing Care Plans = Instructions and education on care, medications and follow-up appointments. Kardex = Updated each shift to document patient care. Signup and view all the answers

The principle of data entry that ensures the writing is clear and easily read by others is called _______________________.

Legibility Signup and view all the answers

What is the purpose of software documentation?

To provide information about software products and systems (C) Signup and view all the answers

Software documentation is not an important part of a software project.

False (B) Signup and view all the answers

What is one benefit of creating software documentation?

Increased Efficiency Signup and view all the answers

Software documentation can help developers and other technical stakeholders understand the technical aspects of the software, leading to ______________ collaboration.

enhanced Signup and view all the answers

What is one of the principles of data entry?

Write only observations that you have seen, heard, smelled, or felt (C) Signup and view all the answers

Match the following principles of data entry with their descriptions:

Accurate = Write only observations that you have seen, heard, smelled, or felt Correct spelling = Need correct spelling, grammar and use of medical terms Use of numbers = Use numbers instead of subjective words like small, large, moderate Signup and view all the answers

Software documentation is only useful for users.

False (B) Signup and view all the answers

What is one common document used by nurses?

User manual Signup and view all the answers

What is the purpose of an Incident Report?

To document error and find a way to prevent the error (A) Signup and view all the answers

Clinical Pathways are used to give end of shift reports.

False (B) Signup and view all the answers

What does SBAR stand for?

Situation, Background, Assessment, Recommendation Signup and view all the answers

Nursing Progress Notes are recorded on all clients but performed differently depending on the ______________________.

institution Signup and view all the answers

Match the types of nursing notes with their descriptions:

Narrative = Information written in sentences or phrases usually time sequenced SOAP = Subjective, objective, assessment, plan PIE = Problem, intervention, evaluation Signup and view all the answers

Acuity charting is used to determine the number of nursing hours required for a patient.

True (A) Signup and view all the answers

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.