Documentation TEST 2

Nurses' notes

1. Pertinent assessment of client 2. Specific nursing care, including teaching and client's responses 3. Client's complaints and how client is coping

The case management model:

1. Promotes collaboration and teamwork among caregivers 2. Helps decrease lengths of stay 3.Improves use of time.

The type of charting done in a source-oriented record is narrative. This means that the entry is written as text with content that includes:

1. Routine care 2. Assessment findings 3. Client problems.

Additional ways to ensure the confidentiality and security of electronic records are to:

1. Use personal passwords to log into and sign out of client computerized files 2. Keep personal passwords confidential by not sharing the password with anyone including other healthcare team members 3. Never leave a computer terminal unattended after logging into the system 4. Close client information after viewing so that it is not displayed on the screen where others might see it 5. Shred all hard copy worksheets or materials that contain client information after being used for care 6. Follow the organization's policies and procedures if an entry error is made 7. Adhere to the organization's policies and procedures for documenting sensitive information, such as a client's HIV positive status.

Conciseness with documentation

Each entry must be brief and complete. The client's name and the word "client" are implied, so these words are omitted. End each thought or sentence with a period.

How can reporting be communicated?

Reporting is communicating specific information, either orally or in writing, to an individual or group.

Consultation records

Reports by medical and clinical specialists

Client discharge plan and referral summary

Started on admission and completed on discharge; includes nursing problems, general information, and referral data

Students are to adhere what with documentation?

Students are to adhere to ethical expectations and legal responsibilities to maintain the confidentiality of client information.

What ensures that client protected health information (PHI) is private and confidential?

The Health Insurance Portability and Accountability Act (HIPAA) of 1996, ensures that client protected health information (PHI) is private and confidential.

Legal documentation

The client medical record is considered a legal document and may be used in a court of law as evidence. The record may be considered inadmissible based on the confidentiality of the client-physician relationship depending on the laws of the state or jurisdiction.

The clinical record gives important information about what?

The clinical record gives important information about the client's health history, which can be used by healthcare providers to determine appropriate interventions and medications.

Who owns the patient records?

The healthcare organization owns the record; however, the client has rights regarding access to and use of the record's contents.

DON'Ts of documentation

1. Leave a blank space for a colleague to chart later 2. Chart in advance of an event, such as a procedure or a medication 3. Use vague terms such as "slept well" 4. Chart for someone else 5. Use "patient" or "client" instead of the client's name 6. Ever alter a record even if requested by a superior or a physician 7. Record words that can reflect a bias such as "argumentative"

Plan of Care with POMR

The initial plan of care is made by referencing to active problems. The care plan is generated by the individual who listed the problem on the problem list. Primary care providers identify the plan of care with orders or medical care plans. Nurses write nursing orders or care plans.

Admission (face) sheet includes what?

1. Legal name, birth date, age, gender 2. Social Security number 3. Address 4. Marital status; closest relatives or individual to notify in case of emergency 5. Date, time, and admitting diagnosis 6. Food or drug allergies 7. Name of admitting (attending) physician 8. Insurance information 9. Any assigned Diagnosis-Related Groups

Medication record

1. Name, dosage, route, time, date of regularly administered medications 2. Name or initials of individual administering the medication

Although narrative charting is a part of the source-oriented record, it is being replaced by other systems. When writing a narrative note, the nurse needs to makes sure that all information is:

1. Organized 2. Coherent 3. Clearly written.

Diagnostic reports Examples:

laboratory reports, x-ray reports, CT scan reports

The client​'s record is a legal document and usually is permissible in court as evidence.​ However, in some​ jurisdictions, the record is excluded as evidence. Which situation would exclude the client​'s record as​ evidence? 1. The client refuses 2. The prosecution refuses 3. The defense refuses 4. The hospital refuses

1. The client refuses

A nurse needs to send a fax containing client protected health information​ (PHI) to another healthcare facility. Which actions by the nurse best protect the client​'s ​PHI? ​(Select all that​ apply). 1. Checking the fax number is correct prior to sending 2. Receiving consent from the client to fax information 3. Ensuring personal identifiable information is contained in the transmittal 4. Using a coversheet with a disclaimer statement 5.Requiring the receiving agency send a signed receipt

1. Checking the fax number is correct prior to sending 2. Receiving consent from the client to fax information 4. Using a coversheet with a disclaimer statement 5.Requiring the receiving agency send a signed receipt

Data can be entered into the computer system through the use of:

1. Bedside computer terminals 2. Handheld devices 3. Speech-recognition technology.

Do's with documentation

1. Chart changes in a client's condition, including follow-up actions taken 2. Read the nurses' notes before providing client care 3. Chart in a timely manner; long periods of time between actual care and documentation could be suspicious 4. Use objective, specific, and factual descriptions Follow organizational policies to correct charting errors 5. Document all client teaching 6. Use quotation marks around actual client words 7. Chart the client's responses to interventions 8. Read the note to make sure it is clear and correctly reflects what needs to be said

Electronic communication:

1. Facilitates the storage of client data 2. Updates data 3. Creates and revises care plans 4. Documents client outcomes.

Disadvantage to using source-oriented records are what?

The major disadvantage of this type of record is that information about a client's problem is scattered throughout the chart. This leads to difficulty finding chronological information about a client's problem and progress, which may lead to: 1. Decreased communication among members of the healthcare team 2. An incomplete picture of the client's care 3. A lack of care coordination.

The record of client care is considered what, and has restricted access to who?

The record of client care is considered a legal document with access restricted to healthcare professionals involved in the direct care of the client.

There are four components to the POMR, what are they?

There are four components to the POMR: database, problem list, plan of care, and progress notes. Flow sheets and discharge notes are added to the chart if necessary.

What order is often used with documentation entries?

There is no particular order followed in writing entries; however, chronological order is often used.

Case Management model

This approach emphasizes high-quality, cost-effective care provided within a pre-determined length of stay. Critical pathways, graphics, and flow sheets are used in this model.

Focus Charting for PIE

This approach places the focus of care on the client's concerns and strengths. With this system, documentation is made in three columns, which are: Date and time Focus Progress notes Progress notes are organized into (D) data, (A) action, and (R) response

What does client medical records help prevent?

This helps prevent fragmentation, repetition, and delays in client care.

Progress Note with POMR

This is a chart entry made by the healthcare professional that provides client care. The notes are numbered to match the number of the problem on the problem list. Entries in the progress notes are written according to the SOAP format. This acronym stands for subjective data, objective data, assessment, and plan. Other renditions of this format are SOAPIE and SOAPIER, which include the categories of interventions, evaluation, and revision.

Problem List with POMR

This is a list of client problems in the order identified. It is usually at the front of the chart and updated as new problems are identified. All healthcare providers contribute to the list. Primary care providers write problems as medical diagnoses, surgical procedures, or symptoms, whereas nurses write the problems using nursing diagnoses. Resolved problems are identified by a line drawn through the problem.

Why would healthcare organizations need to install a firewall?

This is done to protect the organization against hacking, or unauthorized access to the information

Database with POMR

This is the information collected when the client enters the healthcare organization, including: Nursing assessment Client health history Social and family data Results of the physical examination Diagnostic tests. Data is added as the client's health status changes.

source-oriented record

This is the traditional client medical record, and it is organized by each individual or department, having notations in separate sections of the chart. Information about a client's health issue is distributed throughout the record.

Appropriateness with documentation

This means to record information that only pertains to the client's health problems and care. Personal information that does not pertain to the client's health problems is inappropriate and could be considered libelous.

PIE

This system uses a client care assessment flow sheet and progress note. The flow sheet has specific assessment criteria and time parameters. Once the assessment is complete, client problems are written in the progress notes. The problems are numbered. These numbers are then used to identify interventions associated with each problem and evaluation of care provided according to problem. With this system, the traditional care plan is eliminated as an ongoing care plan is integrated within the progress notes.

To ensure the security of computerized confidential client information, healthcare organizations will install what?

To ensure the security of computerized confidential client information, healthcare organizations will install a firewall

To maintain compliance with HIPAA, organizations establish what?

To maintain compliance with HIPAA, organizations establish policies to ensure clients' protected health information remains secure.

What are some reasons professional students access to client records?

Typically organizations permit healthcare professional students access to client records for the purpose of Clinical conferences and rounds, Client studies and to Written papers.

Accuracy with documentation

When documenting in a hard copy medical record, be sure that every page is stamped with the client's name and identifying information. Before writing anything, make sure that the documentation is being written on the correct client's chart. Be vigilant if more than one client on a care area has the same last name. Keep in mind that all entries must be accurate and correct. Document facts or observations, not opinions or interpretations.

Permanence with documentation

When handwriting an entry within a client's medical record, the ink should be blue or black. This is because dark ink reproduces better when scanning or making copies. Red ink should never be used to write a note in a client's medical record. At all times, follow the organization's policies regarding the type of pen and ink to use when documenting.

A client's medical record is a legal document that may be used for evidence in what?

a court case

When documenting, the nurse should also keep in mind the guidelines of

appropriateness, completeness, conciseness, and legal prudence.

The next three guidelines to follow when documenting in a client's medical record are

signature, accuracy, and sequence.

Correct Spelling with documentation

Entries into client medical records should be free of spelling errors. If uncertain as to how to spell a word or medication, take the time to look it up. Examples of medications that can be misspelled with potential major consequences are Fosamax and Flomax.

Special flow sheets

Examples: fluid balance record, skin assessment

Initial nursing assessment

Findings from the initial nursing history and physical health assessment.

Flow sheets with CBE

Flow sheets are used to document data that are assessed over time, such as a vital sign graphic sheet and records of intake and output, daily nursing assessment, client teaching, client discharge, and skin assessment.

Date and Time with documentation

For every entry into the medical record, the date and time must be documented. The time should be recorded using either the 12 hour or the 24 hour clock. For example, if using the 12 hour clock, the time is 7:15 p.m. But if the 24 hour clock is used, this same time is 19:15 hours. Nurses should document the time according to the organization's policy and expectations.

Bedside access to chart forms with CBE

For this system, all flow sheets are kept at the client's bedside. This allows for immediate documentation and eliminates transcribing information from worksheets to the client's permanent record.

Timing with documentation

Frequency of entries should follow the organization's policy but should occur as needed to ensure communication about a client's health status. Documentation should occur as soon as possible after an assessment, intervention, or change in client's condition; no entry should be recorded before the care it describes is provided.

What do healthcare organizations have about policies and procedures?

Healthcare organizations have policies and procedures about recording and reporting client data, including what is to be recorded by registered nurses and what information can be documented by unlicensed assistive personnel.

Why do Healthcare professionals communicate?

Healthcare professionals communicate to ensure quality client care.

Another system of documentation is the problem-oriented medical record (POMR), how is data arranged?

In this system, data are arranged according to client health concerns instead of according to the source of information. All members of the healthcare team contribute to the problem list, care plan, and progress notes.

Completeness with documentation

Information that is documented must be complete and helpful to the client and other healthcare professionals. Nurses' notes should reflect the nursing process. Care that is omitted or refused by the client must also be recorded. If care is omitted, document: What was omitted Why it was omitted Who was notified that it was omitted.

Physician's progress notes

Medical observations, treatments, client progress, and so on

Physician's order sheet

Medical orders for medications, treatments, and so on

Nurses and students are expected to maintain client privacy by not using what?

Nurses and students are expected to maintain client privacy by not using any information that may identify a client, including the client's name or other recognizable information, in class notes, worksheets, or other documents that may leave the organization.

Nurses are accountable for following the who's standards?

Nurses are accountable for following the organization's standards.

Nurses can use the _________ ___________ as a framework when writing a narrative entry.

Nurses can use the nursing process as a framework when writing a narrative entry

Standards of nursing care with CBE

Organizations using the CBE method must have written standards of nursing practice that identify the minimum criteria for client care. Documentation is made according to the standards. If a standard of care is not used or implemented, an asterisk is made on the flow sheet and a narrative explanation recorded in the nurse's notes.

PHI is considered to be...

PHI is considered to be any identifiable health information that is transmitted in any form. This includes Verbal discussions, Electronic communications with or about clients and Written communication.

what may be used to discard hard copy information containing client PHI?

Paper shredders or other containers may be used to discard hard copy information containing client PHI.

Medical history and physical examination

Past and family medical history, present medical problems, differential or current diagnoses, findings of physical examination by the primary care provider

Consultation reports Examples:

Physical therapy, respiratory therapy

PIE documentation stands for?

Problems (P) Interventions (I) Evaluation (E).

Regulatory bodies such as The Joint Commission expect client documentation to be...

Regulatory bodies such as The Joint Commission expect client documentation to be accurate, complete, confidential, and client-specific.

A wound care nurse is invited to attend a client​'s care plan conference. What is true regarding a care plan​ conference? 1. It is usually unacceptable to invite family members. 2. It is usually hosted by the client​'s physician. 3. It is usually made up of a variety of disciplines. 4. It is usually held upon the client​'s admission.

3. It is usually made up of a variety of disciplines.

Faxing of confidential information is a potential privacy concern in healthcare. What security measures should be followed when faxing?

1. Using a cover sheet with a disclaimer statement that the material is only for the named recipient. 2. Receiving consent from the client to fax PHI to the recipient. 3. Removing personal identifiable information or ensuring this information is not on the fax cover sheet. 4. Using the correct fax number by checking the number first, making sure the display is the correct number after dialing, and again before pressing the "send" button on the fax machine 5. Receiving a signed receipt of the sent fax (if expected by the organization).

A nurse is documenting in the​ client's chart and makes a recording mistake. Which action made by the nurse is the most​ appropriate? 1. Drawing three lines through the error and signing next to the entry 2. Drawing one line through the​ error, writing mistaken entry​, and placing initials next to entry 3. Crossing the error out with an​ X and placing initials next to the entry 5. Using correction fluid on the error and signing next to the entry

2. Drawing one line through the​ error, writing mistaken entry​, and placing initials next to entry

A nurse is documenting client information in a​ source-oriented record. What disadvantage does this documentation system​ present? 1. Caregivers differ in their ability to use the required charting format. 2. Information about a particular client problem is scattered throughout the chart. 3. Care providers from each discipline have difficulty locating the forms on which to record data. 4. It is difficult to trace the information specific to each provider​'s discipline.

2. Information about a particular client problem is scattered throughout the chart.

A wound care nurse is invited to attend a​ client's care plan conference. What is true regarding a care plan​ conference? 1. It is usually unacceptable to invite family members. 2. It is usually made up of a variety of disciplines. 3. It is usually held upon the​ client's admission. 4. It is usually hosted by the​ client's physician.

2. It is usually made up of a variety of disciplines.

A nurse is documenting in the client​'s chart and makes a recording mistake. Which action made by the nurse is the most​ appropriate? 1. Using correction fluid on the error and signing next to the entry 2. Crossing the error out with an open double quote"Xclose double quote" and placing initials next to the entry 3. Drawing one line through the​ error, writing, and placing initials next to entry 4. Drawing three lines through the error and signing next to the entry

3. Drawing one line through the​ error, writing, and placing initials next to entry

When documenting client​ care, the nurse adds to the client problem​ list, plan of​ care, and progress notes. What is an advantage of this type of documentation​ system? 1. It provides uniformity among disciplines utilizing the charting format. 2. Care providers from every discipline can easily locate the documentation forms. 3. It encourages collaboration among all disciplines. 4. It is easy to locate the documentation specific to one​'s discipline.

3. It encourages collaboration among all disciplines.

Advantages to using source-oriented records are what?

The major advantages are that it is easy to locate the correct form for recording data and easy to identify the discipline of the healthcare provider who documented in the record.

disadvantage to PIE

A disadvantage to this system is the time needed to read through all of the entries to determine current problems and effective interventions.

Record

A record may be either handwritten or electronic. This type of communication is used when making an entry within a client medical (clinical) record. It is also referred to as recording, charting, or documenting.

Report

A report may be oral, written, or electronic and is used to share information with others. Nurses make reports daily in the form of reporting client care at the end of a hospital shift.

According to the American Nurses Association (ANA) Code of Ethics, nurses have a duty to maintain what?

According to the American Nurses Association (ANA) Code of Ethics, nurses have a duty to maintain confidentiality of all patient information1

Legal Prudence with documentation

Accurate, complete, and thorough documentation legally protects: The nurse Other caregivers The organization The client.

Daily care record

Activity, diet, bathing, and elimination records

Advantages to the POMR approach include

Advantages to the POMR approach include enhanced collaboration among healthcare providers because the problem list appears at the front of the chart, making it easier to track the client's care status.

Legibility with documentation

All handwritten notes must be legible and easy to read. This prevents errors with interpretation. Printing or cursive writing is usually permitted. The organization's policy about handwritten communication should be followed.

Clinical Record

Also referred to as the chart or client record, this is a legal document that identifies all care provided to a client. Although different organizations use different formats or approaches to client clinical records, every client record contains similar information.

Discussion

An oral exchange of information that focuses on one topic or subject. A discussion may be held between two or more healthcare professionals. This form of communication is used to identify or seek solutions to a problem.

Auditing health agencies

Audits of client records are conducted to ensure quality care is being provided. Regulatory agencies such as The Joint Commission may review client records to determine if the organization is meeting accreditation standards.

Sequence with documentation

Be sure to document client care events in the order in which they occur.

Graphic record

Body temperature, pulse rate, respiratory rate, blood pressure, daily weight, and special measurements such as fluid intake and output and oxygen saturation

A system in which only abnormal, changed, or exceptions to the norm are documented describes the what?

Charting by Exception (CBE) documentation method.

Research with documentation

Client information can be used as data for research. Approaches to care for clients with the same health problem can be studied for effectiveness. This information can be used to help other clients with similar health alterations.

Education with documentation

Client records are used as educational tools. The record provides a comprehensive view of the client, the client's health history and current status, treatment strategies, and other information that affects the client's health outcomes.

Healthcare analysis with documentation?

Client records may be used to analyze patterns of resource utilization, identify organization needs, establish costs for services, and identify those services which either generate income or cost the organization money to provide.

Reimbursement with documentation

Documentation is used to receive payment from the federal government, insurance companies, and other third-party payers for health care provided. Health problems are identified by diagnosis-related groupings (DRGs) which are used to assign the anticipated costs for care. Documentation supports the care the client received according to the DRG and may be used to justify additional care needs if the client's treatment or length of hospital stay is affected.

Documentation is written communication used between who?

Documentation is written communication used between nurses and other healthcare professionals to record client care.

Signature with documentation

Each entry made into the medical record is signed by the individual making the entry. This signature is to include the person's name and title. Some organizations have a signature sheet for different parts of the medication record. Once the signature sheet is signed, the nurse can then use initials after a documentation entry. With electronic documentation, each nurse is provided with an identification code, which is used to identify who entered the documentation. At all times, follow the organization's policy to correctly sign a medical record entry.

Accepted Terminology with documentation

Each organization will publish a list of terms, abbreviations, and symbols that are permitted for use within handwritten documentation. For organizations accredited by The Joint Commission, this list will be in compliance with the National Patient Safety Goals to reduce communication errors. The organization will also publish a list of abbreviations, acronyms, and symbols that are not to be used. This list will also be in compliance with The Joint Commission's "DO NOT USE" list

Electronic documentation is a method of documentation through...

Electronic documentation is a method of documentation through a computer system.This approach is helpful to manage large volumes of information.

Disadvantages to the POMR approach include

Disadvantages include variations in the use of the required charting format, maintaining a current problem list, and repeating information that might apply to more than one problem.