NU 205 - documentation and communication

Which data entry follows the recommended guidelines for documenting data?

"Following oxygen administration, vital signs returned to baseline."

The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?

"Only authorized persons are allowed to access client records."

6th purpose of patient record

6. quality assurance- medical records audits, utilizing a peer review process, can be performed to determine whether certain standards of care were met and documented and often lead to changes in care provisions; ongoing quality assurance programs include audits of patient records are a part of accreditation requirements

PIE means

P- problem I- intervention E- evaluation

difference between PIE and SOAP

PIE comes from the nursing process and SOAP comes from the medical model

The following statement is documented in a client's health record: "Patient c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate?

The client reports waking up this morning with a severe headache.

a plan of care is

contains nursing diagnoses, goals, out come criteria, interventions, and evaluation. standardized plans of care may be used bu must always be individualized

what is TeamSTEPPS curriculum

designed to improve patient outcomes by cultivating teamwork among healthcare providers

standardized vocabluary

important for the use in electronic health records, as consistency of terminology makes retrieval of individual and aggregate data possible

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:

interpretation of data

3rd purpose of patient record

3. care planning- availability of all assessment data allows nurses to more accurately develop nursing diagnoses, patient goals, outcome criteria, interventions, and evaluation criteria for the patient plan of care

narrative notes

are when the patient is being quoted, typically used in psychosocial as well as mental health evaluations

c/o means

complains of

goal of CPR

is to have single health related electronic record system for all individuals, so that patient records can be shared to anywhere if needed

a critical pathway is

multidisciplinary tools that identify expected progression of pathways towards discharge. often used for patients requiring complex care of for recently encountered situations

abbreviations

nurse must use abbreviations approved by their facility

SOAP

used for problem oriented charts s- subjective - what the patient tells you o- objective - what you observe /see a- assessment - what you think is going on based on the data p- plan - what you are going to do

FOCUS note

uses DAR D - data = subjective or objective that supports the foucs (conern) A - action = nursing intervention R - response = patients response to an intervention

The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process?

The nurse meets with nurses or other health care professionals to discuss some aspect of client care.

a patient handoff occurs anytime one provider...

transfers the responsibility snd accountability for the care of a patient to another

who owns the patients cart

- a patients chart is the property of the facility

handheld devices

smart phone and tablets allow bedside access to supports as drug information, assessment tools, conversion tables, immunization guidelines, language translation and access to evidence to support clinical decisions

in an incident report

- REMAIN OBJECTIVE - do not blame or admit liability - what did you do? = do not include names of witness or addresses of witness - document time/name of doctor - do not file in chart - goes to HR - do not write "incident report made"

types of patient records - problem oriented

- commonly referred to as POR - organized according to problem - four parts 1- data base = patients present health status 2- problem list= numbered list of health problems 3- initial plan = plan to help overcome health problems 4- progress notes = all disciplines chart on same page

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply.

-any abnormal occurrences with the client during the shift -identifying demographics, including diagnosis -current orders

types of nursing notes are

1- narrative notes 2- SOAP notes 3- PIE notes 4- FOCUS DAR notes

the joint commission identified ...

critical communication failure as one of the most common root causes responsible for sentinel events during 2004 to 2014

absent or inaccurate or delayed communication can subject the patient to ...

serious risks or delayed recovery

flow sheet is

tables with vertical and horizontal columns allowing for documentation of routine assessments and procedures

a joint commission national patient safety goal is ....

that all agencies have a standardized approach (template) to handoff communications

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication?

"I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin."

research is used

- as data on treatments, meds, and therapy - as info for tumor boards, doctors rounds, nursing rounds etc. - be aware of privacy issues - nurses, student nurses use for care plans

sharing information

- facilities exchange of information between staff - prevents duplication errors in meds, dressing change, activity, diets, etc.

nurse entries in patient records

- flow sheets - plan of care - critical pathways

corrections on charts

- if u spill something on a chart do not discard it, recopy and put the recopy and original back in the chart and write copy on the copy - do not scribble out charting - follow your facilities policy - do not alter charting, IT IS A LEGAL DOCUMENT

types of patient records - source oriented

- most traditional - different disciplines chart on separate forms - each reader must consult various parts of the record to get a complete picture - record become bulky

kardex

- quick reference of patient information - change as needed, often in pencil - not part of the permanent record

patients rights

- they have the right to have heath care information protected - they have the right to read and copy their own medical record - the right to ask that your doctor change the record if it is not correct, relevant, or complete

change in shift report

- utilize SBAR - person to person - be prepared - avoid gossip and socialization - maintain professionalism even when others are not - may use a tape recorder

Which are examples of breaches of client confidentiality? Select all that apply.

-A nurse discusses information about a client with a coworker in the elevator. -A nurse shares his or her computer password with another nurse who was unable to log in to the system. -A nurse updates the employer of a client regarding the client's date of return to work.

1st purpose of patient record

1. communication - tells the plan of care and the patient progress to all healthcare team members; conveys a clear picture of patient through different viewpoints and at different times; ensures continuity of care and provides data for evaluation and revision or continuation of care

principles of documentation #2

2. accurate - should be things that can be seen, heard, felt, or smelled. proofread when documenting these findings and do not alter once documented

principles of documentation #3

3. concise and complete - use partial sentences and phrases , do not include patient name in narrative charting and only use abbreviations approved by facility

9th purpose of patient records

9. education - contains valuable educational information that allows students to relate patient signs and symptoms, interventions and outcomes

The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. Which technique would be most appropriate for the nurse to use when communicating with the health care provider?

SBAR

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss?

Subjective data should be included when documenting.

TeamSTEPPS means

Team Strategies and Tools to Enhance Performance and Patient Safety

A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message, "You are not authorized to view this information." What is the reason for this message?

The laboratory assistant can only retrieve patient records but cannot view the details.

Which strategy would provide the most effective form of change of shift report?

Utilizing a reporting form and allowing time for any questions.

Which documentation tool will the nurse use to record the client's vital signs every 4 hours?

a flow sheet

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of:

a referral

Acuity charting forms

allow nurses to rank clients as high to low acuity in relation to the client's condition and need for nursing assistance or intervention.

clinical surveillance tools

automated surveillance tools that scan electronic health record data and produce a real time patient risk score for designated high risk conditions

What is the primary purpose of the client record?

communication

what is the A in SBAR

it is the assessment: what is the problem

what is the B in SBAR

it is the background: what are the circumstances leading up to this situation

what is the R in SBAR

it is the recommendations: what should be done to correct the problem

Which are appropriate actions for protecting clients' identities? Select all that apply.

-Document all personnel who have accessed a client's record. -Place light boxes for examining X-rays with the client's name in private areas. -Have conversations about clients in private places where they cannot be overheard

The nurse is caring for a client who has been physically restrained. Which observation(s) will the nurse include when documenting the client's care? Select all that apply.

-The client exhibits agitation and shouts at the nurse. -The client's blood pressure is 135/82 mm Hg. -The client's skin turgor is normal. -The client has redness around the ankles bilaterally. -The client participates in range-of-motion exercises.

things to think about when Charting by excepting (CPOE)

-uses flowsheets - emphasis on abnormal - but also think is what is abnormal for the "normal" patient, abnormal for THIS patient = if so then it is no longer considered an exception

principles of documentation #1

1. confidential - keeping information private is ethical and legally required. hipaa protects PHI confidentiality, this applies to written and computerized medical records

2nd purpose of patient record

2. assessment- allows comparison of objective and subjective assessment data gathered by all team members to determine current health status and progress towards goals

At 8:15 p.m., a client reports pain, and the nurse administers the prescribed analgesic. When documenting this intervention using military time, which time would the nurse use?

2015

4th purpose of patient record

4. care provided - tracks progress, care given and patient response to care

principles of documentation #4

4. objective - use direct quotes to remain objective when documenting psychosocial and mental health issues in particular; patient behavior should be described rather than interpreted

5th purpose of patient record

5. legal document- can be used in court to prove or disprove injuries a patient incurred unintentionally or to implicate or absolve a health care professional with response to improper care -permanent account - filed in medical records department

principles of documentation #5

5. organized and timely - document things in order that they occurred and include patient response to intervention, timely documentation reduces risk of forgetting important information, document all medication and procedures upon time of completion.

7th purpose of patient records

7. reimbursement - provides basis for decision regarding care and subsequent reimbursement to the agency; lack of documentation may result in denial for payments from medicare and private insurance companies = this puts the burden of the payment on the patient

8th purpose of patient records

8. research - nursing and healthcare research is often carried out using patient records. accurate documentation helps assure that research outcomes are valid and reliable

Which clinical situation is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)?

A client has asked a nurse if he can read the documentation that his physician wrote in his chart.

what is the S in SBAR

it is the situation: what is happening at that present time

The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which drawback?

vulnerability to legal liability since nurse's safe, routine care is not recorded