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Questions and Answers
Which type of report is given at the end of a shift so that the next nurse can follow the appropriate treatment plan and care for the patient?
Which section of the health record includes information needed to contact the guardian of a patient?
Which system in the electronic health record (EHR) provides warnings to alert a health care provider of patient allergies when prescribing medications?
Which organization addresses the quality of health care documentation? --SATA--
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In which section of the patient health record would the nurse enter subjective and objective data?
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Which characteristic is an advantage of effective documentation? ---SATA---
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Which section of the health record maintains patient demographic information?
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Which type of documentation is based on the concept that all standards for normal assessment findings or for routine care activities are met unless otherwise documented?
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Which standardized assessment tool is used for receiving health care funding from the Centers for Medicare and Medicaid Services? ---SATA----
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Which element is included in the SOAP note?
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Which mechanism provides warnings to alert the nurse of a potential patient safety risk?
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Which step of the SOAP (subjective, objective, assessment, plan) format documentation reflects the nurse's interpretation of patient data?
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Which system helps health care organizations comply with the requirements of accrediting agencies?
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Which system is involved in providing built-in reminders and alerts for prescribing medications and diagnostic tests?
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Which statement made by the nurse is true regarding clinical information systems (CIS)?
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Which action would the nurse perform after receiving new patient prescriptions from a health care provider by telephone? ---SATA----
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Which information would the nurse provide in the discharge summary for a patient being discharged home? -----SATA----
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Which statement made by a student nurse indicates the need for additional teaching?
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What is the purpose of providing detailed documentation in the home care setting? ----SATA----
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Which actions meet legal guidelines for nursing documentation? ----SATA----
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Which item is a feature of charting by exception? ----SATA-----
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Which outcome is expected from effective documentation? ----SATA-----
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Which statement describes the purpose of the incident report? ---SATA----
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Which charting error can lead to malpractice lawsuits? ----SATA----
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Which patient information would the nurse exclude from mentioning during an educational conference? ----SATA----
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Which is the mode for exchanging information among members of the health care team? ----SATA----
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Which statement includes the factual details required for documentation in the nursing care record? ----SATA----
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In which ways does SOAP charting differ from problem-intervention-evaluation (PIE) charting? ---SATA----
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Which statement by the nurse requires the manager to advise the nurse on the correct techniques of documentation used in a hand-off report? ---SATA---
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Study Notes
Shift Report
- A shift report is given at the end of a work shift to the next nurse who will be taking care of the patient.
Patient Demographics
- The section of the health record that contains patient demographic information is called the "Patient Registration" or "Demographics" section.
Patient Guardian
- This information is usually found in the "Patient Registration" or "Demographics" section of the health record.
Electronic Health Record (EHR) System: Medication Allergy Warnings
- The EHR system uses an "allergy management" system which displays medication allergy warnings when a health care provider prescribes medications.
Quality of Health Care Documentation
- The organization that addresses the quality of health care documentation is the The Joint Commission (TJC).
Subjective & Objective Data
- The "Nursing Notes" or "Progress Notes" sections of the patient health record is where the nurse will document subjective and objective data.
Advantages of Effective Documentation
- Effective documentation is clear, concise, accurate, and timely.
- It helps ensure continuity of care and improves patient safety by allowing healthcare providers to access important information.
Documentation Based on Routine Care Activities
- This is known as "charting by exception" which means that the nurse will only document deviations from the norm.
Standardized Assessment Tool: Centers for Medicare and Medicaid Services
- The Minimum Data Set (MDS) is a standardized assessment tool used by skilled nursing facilities to collect information about residents to determine their needs for care.
- This tool helps determine eligibility for Medicare and Medicaid funding.
SOAP Note Elements
- The SOAP note format includes the following elements:
- Subjective (S): Includes information provided by the patient.
- Objective (O): Includes factual data observed by the nurse.
- Assessment (A): The nurse's interpretation of subjective and objective data, including patient diagnosis.
- Plan (P): Includes the plan for future care.
Patient Safety Risk Warnings
- Warnings alerting the nurse to potential patient safety risks can come from various sources.
- Some common sources include EHR systems that incorporate automated reminders and alerts, and the use of "clinical decision support" systems.
SOAP Note: Assessment
- The nurse's interpretation of patient data is documented in the "Assessment" section of the SOAP note format.
Requirement Compliance with Accrediting Agencies
- EHR systems help healthcare organizations fulfill the requirements of various accrediting agencies, such as The Joint Commission (TJC).
EHR System: Medication & Diagnostic Reminders
- Electronic health record (EHR) systems that include clinical decision support (CDS) systems are used to provide built-in reminders and alerts for prescribing medications and diagnostic tests.
Clinical Information Systems (CIS)
- Clinical information systems (CIS) are designed to help nurses with different tasks, including:
- Charting.
- Medication administration.
- Patient monitoring.
- Order entry.
New Prescription: Actions
- The nurse should take the following actions after receiving new prescriptions from a health care provider by telephone:
- Immediately document the order in the patient's medical record.
- Read back the order to the provider to ensure accuracy.
- Ensure the provider signs the order as soon as possible.
Discharge Summary Information
- The discharge summary for a patient being discharged home should include:
- The patient's final diagnosis.
- A summary of the patient's hospital stay.
- Discharge instructions.
- Prescriptions for medication and home health services.
Documentation: Student Nurse Needs Further Teaching
- A student nurse who states that documentation is only for legal reasons needs further teaching.
- Documentation serves many purposes, such as improving patient care and communication between healthcare professionals.
Documentation: Home Healthcare Setting
- Detailed documentation in the home care setting is crucial for:
- Promoting patient safety.
- Ensuring continuity of care.
- Monitoring the effectiveness of care.
- Reimbursement for services.
Documentation: Legal Guidelines
- The nurse should follow these guidelines for documentation:
- Use clear, concise language.
- Record factual information.
- Document all significant interactions and events with patients.
- Correct errors properly.
Charting by Exception
- Key features of charting by exception include:
- Documentation only when there are deviations from established norms.
- Focus on abnormal findings.
- Assumption that all standards are met unless otherwise documented.
Effective Documentation
- Effective documentation leads to these good outcomes:
- Facilitates communication between healthcare providers.
- Ensures continuity of care.
- Promotes patient safety.
- Provides a legal record of care.
Incident Report Purpose
- The purpose of an incident report is:
- To document any unexpected occurrence that could have resulted in or did result in harm to a patient.
- To identify potential hazards and risks in the healthcare setting.
Malpractice Lawsuits: Charting Errors
- Charting errors can contribute to malpractice lawsuits, especially:
- Charting late entries.
- Failing to document assessments, interventions, and patient responses.
- Omitting essential information.
- Leaving blank spaces in documentation.
Patient Information: Educational Conference
- Patient information that should be excluded from educational conferences includes details that could violate the patient's confidentiality.
- This could include:
- Patient name and address.
- Specific details about their medical condition.
- Identifying characteristics.
Information Exchange: Health Care Team
- The modes for exchanging information among members of the health care team include:
- SBAR (Situation, Background, Assessment, Recommendation) - A standardized communication tool.
- Shift reports
- Handoff reports
- Verbal communication
Nursing Care Record Documentation
- The nursing care record must include factual details, such as:
- Date and time of assessment, interventions, medications, and procedures.
- Observations related to the patient's condition.
- Patient's response to interventions.
SOAP & PIE Charting: Differences
- The main differences between SOAP and PIE charting includes:
- SOAP charting focuses on problems identified by the nurse and outlines a plan of care for each problem.
- PIE charting focuses on patient problems, interventions, and evaluation of the effectiveness of interventions.
Documentation: Hand-Off Report
- A manager should advise a nurse on the correct techniques of documentation used in a hand-off report if the nurse's statements include phrases such as:
- "Just make a note if there's a problem."
- "Don't worry, we'll just take care of that."
- "The patient is doing fine."
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Description
Test your knowledge on the types of reports used in nursing. This quiz focuses on the essential information that must be communicated to ensure continuity of patient care during shift changes. Discover the various reporting methods and their importance in nursing practice.
