22 Questions
What is one of the purposes of documentation in healthcare?
All of the above
Illegible writing can cause harm to patients due to wrong treatment or lack of treatment.
True
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
What principle of data entry ensures that the source of the finding is identified?
Objectivity
Nursing Care Plans are created at discharge.
False
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.
The principle of data entry that ensures the writing is clear and easily read by others is called _______________________.
Legibility
What is the purpose of software documentation?
To provide information about software products and systems
Software documentation is not an important part of a software project.
False
What is one benefit of creating software documentation?
Increased Efficiency
Software documentation can help developers and other technical stakeholders understand the technical aspects of the software, leading to ______________ collaboration.
enhanced
What is one of the principles of data entry?
Write only observations that you have seen, heard, smelled, or felt
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
Software documentation is only useful for users.
False
What is one common document used by nurses?
User manual
What is the purpose of an Incident Report?
To document error and find a way to prevent the error
Clinical Pathways are used to give end of shift reports.
False
What does SBAR stand for?
Situation, Background, Assessment, Recommendation
Nursing Progress Notes are recorded on all clients but performed differently depending on the ______________________.
institution
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
Acuity charting is used to determine the number of nursing hours required for a patient.
True
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
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.
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