Chapter 7 (documentation)

What is SOAP?

is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note

accuracy in documentation

-Be specific and definite in using words or phrases that convey the meaning you wish expressed -Words that have ambiguous meanings and slang should not be used in charting

What to document

-Completeness is more important than brevity

Electronic Health Record (EHR)

-Computerized record of patient's history and care across all facilities and admissions

The medical record

-Contains data about patient's stay in a facility -Only health care professionals directly caring for the patient, or those involved in research or teaching, should have access to the chart -Patient information should not be discussed with anyone not directly involved in the patient's care

LEGIBILITY AND COMPLETENESS IN DOCUMENTATION

-If writing not legible, misperceptions can occur -Be sure to include as much information as needed

Brevity in documentation

-Sentences not necessary -Articles (a, an, the) may be omitted -The word "patient" omitted when subject of sentence -Abbreviations, acronyms, symbols acceptable to the agency used to save time and space -Choose which behaviors and observations are noteworthy

What is a care flow sheet?

form on which check marks or short entries are made to indicate dietary intake, type of bath, would dressing changes, oxygen in use, health care provider visits, equipment in use, level of activity, & initial assessment or abnormal findings -track routine assessment, treatments, and given care

What is the medical record a property of?

health facility or agency

Monica, a nurse in the operating room, knows that charting must be all of the following except: 1)subjective. 2)accurate. 3)brief. 4)complete.

1) subjective

Madison, a pediatric nurse, prefers charting by exception. She realizes all of the following are true except: 1)charting by exception was developed in 2005 by a group of nurses at St. Luke's Medical Center in Sarasota, Florida. 2)the goal is to decrease the lengthy narrative entries of traditional systems. 3)charting by exception is based on the assumption that all standards of practices are carried out. 4)a longhand note is written only when the standardized statement on the form is not met

1)charting by exception was developed in 2005 by a group of nurses at St. Luke's Medical Center in Sarasota, Florida.

Sally went into her patient's room to administer an antibiotic. Her patient states, "I am not going to take another pill because they aren't working." What should Sally do? 1) Leave the pill on the bedside table and come back in a few minutes. 2) Throw the pill in the trashcan. 3)Circle the medication on the medication record, give a reason for the refusal in the progress notes, and notify the physician. 4)Crush up the medication in the patient's food and inform the charge nurse

3)Circle the medication on the medication record, give a reason for the refusal in the progress notes, and notify the physician

Mrs. Smith, LPN, has just charted the following assessment on her patient. 2/14/2008 3:00 PM VS stable. Voided 450 mL clear straw-colored urine. Pt denies pain but appears tired. Amy Smith, LPN Which of the following entries is incorrect? 1) Time of entry 2)Nurse stating an opinion 3)No line before name 4)All of the above

4)All of the above

What does SOAP stand for?

S: subjective O: objective A: assessment P: plan

What are computer-assisted charting advantages? (select all apply) a) Date and time of the notation automatically recorded b) Notes always legible and easy to read c) Sophisticated security system needed to prevent d) Initial costs are considerable e) Quick communication among departments about patient needs f) Many providers have access to patient's information at one time

a) Date and time of the notation automatically recorded b) Notes always legible and easy to read e) Quick communication among departments about patient needs f) Many providers have access to patient's information at one time

What are source-oriented charting disadvantages? (select all apply) a) Discourages physicians and other health team members from reading all parts of the chart b) Indicates aspects of all steps of the nursing process c) Requires extensive charting time by the staff d) Documents patient's baseline condition for each shift e) Documents all findings: makes it difficult to separate pertinent from irrelevant

a) Discourages physicians and other health team members from reading all parts of the chart c) Requires extensive charting time by the staff e) Documents all findings: makes it difficult to separate pertinent from irrelevant

What are charting by exception advantages? (select all apply) a) Highlights abnormal data and patient trends b) Decreases narrative charting time c) Requires detailed protocols and standards d) Nurses so used to not charting that important data is sometimes omitted e) Eliminates duplication of charting

a) Highlights abnormal data and patient trends b) Decreases narrative charting time e) Eliminates duplication of charting

What is source-oriented charting? (select all apply) a) Organized according to source of information b) A longhand note is written only when the standardized statement on the form is not met c) Variations depending on the system d) Separate forms for nurses, physicians, dietitians, and other health care professionals to document assessment findings and plan the patient's care e) Narrative charting requires documentation of patient care in chronological order

a) Organized according to source of information d) Separate forms for nurses, physicians, dietitians, and other health care professionals to document assessment findings and plan the patient's care e) Narrative charting requires documentation of patient care in chronological order

What is computer assisted charting? (select all apply) a) Some produce flow sheets with nursing interventions and expected outcomes b) Organized according to source of information c) Documentation done as interventions are performed using bedside computers d) Variations depending on the system e) Others use a POMR format to produce a prioritized problem list

a) Some produce flow sheets with nursing interventions and expected outcomes c) Documentation done as interventions are performed using bedside computers d) Variations depending on the system e) Others use a POMR format to produce a prioritized problem list

What are computer-assisted charting disadvantages? (select all apply) a) Sophisticated security system needed to prevent b) Initial costs are considerable c) Many providers have access to patient's information at one time d) Implementation can take a long time e) Quick communication among departments about patient needs

a) Sophisticated security system needed to prevent b) Initial costs are considerable d) Implementation can take a long time

What is all in the care plan? (select all apply) a) nursing dx b) goals c) current history d) expected outcomes e) usual habits f) nursing interventions

a) nursing dx b) goals d) expected outcomes f) nursing interventions

What are examples of a face sheet? (select all apply) a) patient data b) expected outcomes c) patients name, address, phone number, & next of kin d) hospital ID #, religious preference, & place of employment e) medications, lab tests, ex-ray exams f) admitting dx, name of admitting health provider, & occupation

a) patient data c) patients name, address, phone number, & next of kin d) hospital ID #, religious preference, & place of employment f) admitting dx, name of admitting health provider, & occupation

What is charting by exception? (select all apply) a) Narrative charting requires documentation of patient care in chronologic order b) A longhand note is written only when the standardized statement on the form is not met c) Some produce flow sheets with nursing interventions and expected outcomes d) Based on the assumption that all standards of practice are carried out and met with a normal or expected response unless otherwise documented e) Others use a POMR format to produce a prioritized problem list

b) A longhand note is written only when the standardized statement on the form is not met d) Based on the assumption that all standards of practice are carried out and met with a normal or expected response unless otherwise documented

What are computer-assisted charting advantages? (select all apply) a) Implementation can take a long time b) Can reduce documentation time c) Quick retrieval of electronic records d) Significant cost and time to train staff to use the system e) Reimbursement for services rendered is faster and complete f) Can reduce errors

b) Can reduce documentation time c) Quick retrieval of electronic records e) Reimbursement for services rendered is faster and complete f) Can reduce errors

What are source-oriented charting advantages? (select all apply) a) Requires extensive charting time by the staff b) Information in chronologic order c) Documents patient's baseline condition for each shift d) Documents all findings: makes it difficult to separate pertinent from irrelevant e) Indicates aspects of all steps of the nursing process

b) Information in chronologic order c) Documents patient's baseline condition for each shift e) Indicates aspects of all steps of the nursing process

What are charting by exception disadvantages? (select all apply) a) Highlights abnormal data and patient trends b) Requires detailed protocols and standards c) Requires staff to use unfamiliar methods of record keeping and recording d) Eliminates duplication of charting e) Nurses so used to not charting that important data is sometimes omitted

b) Requires detailed protocols and standards c) Requires staff to use unfamiliar methods of record keeping and recording e) Nurses so used to not charting that important data is sometimes omitted

What are computer-assisted charting disadvantages? (select all apply) a) Can reduce documentation time b) Significant cost and time to train staff to use the system c) Computer downtime can create problems of input, access, and transfer of information d) Can reduce errors

b) Significant cost and time to train staff to use the system c) Computer downtime can create problems of input, access, and transfer of information

EMR (electronic medical record)

computerized record of one physician's encounters with a patient over time