Software Documentation in Nursing Informatics

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Questions and Answers

What is the purpose of an Incident Report?

To identify and prevent errors such as falls and medication errors (correct)

To record vital signs

To assign acuity numbers to patients

To document medication administration

What is the purpose of documenting care planning in nursing documentation?

To identify the source of the finding

To plan for patient discharge

To assess the quality of care provided

To develop a plan of care based on objective and subjective data (correct)

What is the main purpose of Clinical Pathways?

To document patient vital signs

To assign nursing hours to patients

To communicate patient information to other healthcare professionals

To standardize care and improve patient outcomes in a cost-effective manner (correct)

What is the importance of conciseness in nursing documentation?

To allow for the use of approved abbreviations Signup and view all the answers

What is the purpose of the Admission History and Assessment document?

To provide information on the client's previous state prior to hospitalization Signup and view all the answers

What is the primary function of a Medication Administration Record (MAR)?

To document medications administered to patients Signup and view all the answers

What is the main purpose of SBAR?

To provide a framework for communication Signup and view all the answers

Why is legibility important in nursing documentation?

To reduce errors due to illegibility Signup and view all the answers

What type of nursing note is written in sentences or phrases and is usually time-sequenced?

Narrative Signup and view all the answers

What is the purpose of the Kardex document?

To update the patient care record each shift Signup and view all the answers

What is an important purpose of documentation in nursing practice?

To communicate with other healthcare professionals Signup and view all the answers

What is the primary function of Acuity charting?

To assign nursing hours to patients based on care requirements Signup and view all the answers

What is the purpose of the Flow Sheets/Graphic Sheets document?

To document assessment findings and routine care activities Signup and view all the answers

Why is completeness important in nursing documentation?

To prevent delay in treatment due to omitted data Signup and view all the answers

What is software documentation?

A type of documentation that provides information about software products and systems Signup and view all the answers

What is one of the benefits of creating software documentation?

Increased efficiency Signup and view all the answers

What is an important principle of data entry in nursing informatics?

Use of numbers instead of descriptive words Signup and view all the answers

Why is software documentation important for developers?

It provides clear, consistent, and up-to-date information about the software Signup and view all the answers

What is another benefit of creating software documentation?

It enhances collaboration Signup and view all the answers

What type of information should be included in user manuals?

Step-by-step instructions for common tasks Signup and view all the answers

Why is accurate documentation important in nursing informatics?

It helps ensure patient safety Signup and view all the answers

What should be avoided in data entry in nursing informatics?

Use of subjective words Signup and view all the answers

Study Notes

Software Documentation

Software documentation is a type of documentation that provides information about software products and systems.
It is an important part of a software project, providing clear, consistent, and up-to-date information about the software.

Benefits of Creating Software Documentation

Increased efficiency: provides quick access to necessary information, reducing the time spent searching for answers.
Enhanced collaboration: helps developers and other technical stakeholders understand the technical aspects of the software, promoting collaboration and consistency.

Principles of Data Entry

Accurate: write only observations that you have seen, heard, smelled, or felt, using objective language and accurate measurements.
Complete: ensure all data and information are noted for the shift, including nursing interventions, medication, and client teaching.
Concise: use brief and approved abbreviations to convey information.
Timelines: document care, treatments, and procedures as soon as possible.
Objective: identify the source of the finding, using objective language.
Legible: writing must be clear and easily read by others, with a legible signature.
Organization: entries should show a logical and systematic grouping of information, using the nursing process.

Purpose of Documentation

Communication: provides 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, certain diagnoses, which must be documented.
Legal documentation: protects healthcare professionals and institutions.
Research: charts can be reviewed for trends and patient outcomes.
Education: can be used to teach patients, such as blood sugar data.

Common Documents Used by Nurses

Admission History and Assessment: provides information on the client's previous state and reason for seeking medical care.
Discharge Form: provides instructions and education on care, medications, and follow-up.
Nursing Care Plans: outlines the plan of care started on admission with nursing diagnosis and outcomes.
Flow Sheets/Graphic Sheets: documents assessment findings and routine care activities performed repeatedly throughout a shift.
Kardex: a patient care record updated each shift, including IV fluids, treatments, and therapies.
Clinical Pathways: outlines key interventions for each patient with a specific diagnosis, standardizing care and improving outcomes.
Medication Administration Records (MAR): documents medications given.
Nursing Progress Notes: records progress on all clients, performed differently depending on the institution.
Acuity charting: assigns a number to procedures and care to determine nursing hours required for the patient.
Incident report: documents errors and finds ways to prevent them.

Types of Nursing Notes

Narrative: information written in sentences or phrases, usually time-sequenced.
SBAR: a framework for communication, providing structured and orderly approach to communication.
SOAP: subjective, objective, assessment, plan.
PIE: problem, intervention, evaluation.
SOAPIER: subjective, objective, assessment, plan, intervention, evaluation, reassess.

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Description

This quiz covers the basics of software documentation, its importance, and principles of data entry in the context of nursing informatics. It also explores the common documents used by nurses.