Chapter 18: Documentation

Nursing documentation should be which of the following? Select all that apply. A. Accurate B. Nonjudgmental C. Specific D. Opinionated E. Dispensable

A, B, C

Which are outcomes of effective nursing documentation? Select all that apply. A. Safe nursing practice B. Continuity of client care C. Efficient time management D. Cost-conscious nursing care E. Effective nurse-client relationships

A, B, C

The nurse is reviewing documentation forms in the facility where she was recently hired. What are some commonly used forms? Select all that apply. A. Checklists B. Medication administration records C. Intake and output records D. Care plans E. Kardex

A, B, C, D, E

What are some advantages of electronic records? A. More secure B. Saves time for nurses C. Can transfer information to multiple departments D. Can be used by several people at once E. Neater and easier to read F. Less repetition G. Less "down time" H. More accurate

A, B, C, D, E, F, H The use of the electronic health record has been shown to significantly reduce human error. Many systems can auto-populate with compatible electronic equipment (IV pumps, vital sign equipment, etc.) and provide "safety warnings" if the wrong medication is about to be given or there is an allergy. These systems are becoming more advanced all the time.

Which are document expectations? A. Accurate B. Complete C. Detailed D. Bias free E. Readable F. Defensible G. Extensive

A, B, C, D, F The ABCs of documentation say that documents should be Accurate, Bias free, Complete, Detailed, Easy to read, Factual, Grammatical, Harmless (legally)

An informatics nurse is training a group of students on the advantages of using an EHR. What could be some supporting reasons? Select all that apply. A. Can be used by several team members simultaneously B. Less repetition of data C. More accurate reporting D. Less "down time" E. Faster

A, B, C, E

Which abbreviations are on The Joint Commission's "do not use" list? A. U or u B. Q.O.D. C. q for every D. Q.D. for daily E. MS for magnesium sulfate F. oz for ounce G. Lack of leading zero (.X mg) H. IU

A, B, D, E, G, H The use of abbreviations in healthcare documentation has been a practice for decades. In the past 20 years, we've become much more aware of patient safety and human errors in healthcare delivery. With this knowledge, abbreviations have been identified as a high-risk area for human injury caused by misunderstanding of their meaning.

What are some common charting formats? A. Narrative B. Focus Charting® C. Emergency D. Exception E. Medication Administration Record F. Summarize, Organize, Assessment, Plan, Implement, Evaluate G. Problem—Intervention—Evaluation H. SOAPIE

A, B, D, G, H Problem-Intervention-Evaluation (PIE) charting focuses on patient problems by identifying the problem, telling what the nurse did about it, and evaluating the client's response to the intervention. Narrative documentation tells a chronological story in words. For example, some nurses write a sequence of events and the subsequent actions taken as they unfold. DAR is the acronym for data, action, and response, a column used with Focus Charting®; the other two columns in this system contain date and time and the focus, or problem, addressed in the note. Charting by exception, another format, refers to a system in which only the exceptions to standards are documented. For example, if a client did not meet a specific standard, a documentation note is made. The SOAPIE note is another format used to write nursing and other progress notes. SOAPIE stands for Subjective data, Objective data, Assessment, Plan, Interventions, and Evaluation.

What is the purpose of documentation? A. Creating legal report of care delivery B. Allowing nurses to summarize physician findings C. Facilitating communication among team members D. Providing consistent care from shift to shift E. Improving the facility's care quality F. Tracking the nurses on each shift G. Sharing data with insurance companies

A, C, D, E Charting provides a record for communication, continuity of care, quality improvement, planning and evaluation of client outcomes, and legal protection, among other things. It needs to be complete, accurate, and timely. Insurance companies may use documentation to determine payment or deny reimbursement, but the intention of documentation is not for insurance companies. The record must be focused on the patient, not on what the nurse has done. Nurses may only document their own assessment and care.

Which are common forms of oral communication? A. Kardex B. SBAR C. Bedside report D. Face-to-face report E. Telephone orders F. Verbal orders G. Transfer report H. Handoff report

B, C, D, E, F, G, H Oral communication among healthcare team members is important. As with written or electronic communication, it has a high incidence of human error. It is critical for nurses to communicate clearly and accurately to prevent costly mistakes.

Which are commonly used documentation forms? A. Family relationship form B. Occurrence report C. Admission data forms D. History and physical E. Flow sheets and graphic records F. Hand-off report G. Student tracking form H. Discharge summary

B, C, D, E, H A variety of forms are used in the patient record, including admission data forms, discharge summary, flow sheets, graphic records, checklists, medication administration records, intake and output records, care plans, and Kardex. Additional documentation forms that are not kept with the patient record include occurrence reports, which record an incident of risk or potential risk. These are typically kept by the administration of the agency.

The nurse documents: D: The client is wheezing and experiencing some shortness of breath with exertion A: Delivered 2 puffs of inhaler. R: Wheezing lessened after 5 minutes. Which type of documentation is this an example of? A. PIE B. Charting by exception C. Focus Charting® D. Narrative

C

Which are common documentation guidelines for nurses? A. Document ahead when possible. B. Use block charting. C. Document after each observation. D. Document throughout the shift. E. Use chronological order. F. Never use late entries.

C, D, E Documentation should be timely, accurate, chronological, and consistently performed. When a nurse is caring for multiple clients, details may be easily forgotten or confused, so documenting after each observation and throughout the shift is important. A nurse cannot document ahead because that would record what he or she thinks will happen and not the facts of what actually happened. Block charting is the use of time ranges and should be avoided. Specific details are most accurate. Late entries are acceptable when a nurse has forgotten to document something, but should be noted as a "late entry."