NRS 113 Documentation

What are the ABCs of charting?

Accurate, Brief, Complete

Nurses are responsible for 4 types of documentation forms. What are they?

Admission database Flowsheets Medication Administration Records (MAR) KARDEX or client care summary

What goes on the discharge report/summary?

time pt left, ambulation status, who they left with, how they physically left facility, condition at d/c, and any pt ed

What are flowsheets, give exampes

used to record routine care. Ex: QD assessment, client response to care, VS trends, Is&Os.

What is the purpose of change-of-shift repot?

continuity of care, oncoming staff opportunity to ask questions.

What info is listed in the Medication Administration Record (MAR)?

date/time of medication, medication name, lot #, expiration date, site of injection, route, dose, allergy and pt reaction

Define Admission Database and its' uses

Baseline records, begins when they walk through door. Includes: cc/reason for admission, vitals, allergies + reaction, medication list including last dose + time taken, ADL/discharge info we may need to know and any support they have.

General rules of documentation

Black or blue ink, avoid subjective terms, authorized abbreviations only, don't leave lines blank, if error-draw single line through & initial.

What is focus charting?

Data (subj/obj info) Action (aka intervention) Response (like eval)

T/F You can leave the rest of line you are writing on black after completing your charting?

False. Draw a line through the remaining space, then sign.

SOAP charting has IER, define this

Intervention: what we do to carry out our plan Evaluation: how did it work Revise: what do we need to adjust?

What should be done when receiving telephone order?

Must be repeated to decrease error seen as "RB." You must transcribe it into the pt chart. Spell out the medication over the phone to ensure accuracy. Do not take second hand telephone info.

Is the KARDEX/Client Care Summary part of the pt record?

No. We see this frequently in ICU setting. It's a "snapshot" updated by unit secretary.

Is the document for long term care the same as acute care?

No. You don't document as much at LTC as AC. Typically updated Q3M

T/F You should always take a verbal order because it is in our scope of practice

No. You should only take a verbal order in an emergent situation and you should get a written order ASAP.

What is Pie Charting?

Problem oriented. Problem Intervention Evaluation

Define SOAP charting

Subjective Objective Assessment Plan

What is KARDEX or client care summary? What does it include?

Summary of pt info in quick glance format. Includes: demographic data, dx, allergies, diet/activity/ tx/ med orders, safety precautions, any special instructions.

T/F Do not chart that you filled out an occurrence report?

True. DO NOT document this because it is then a part of the permanent record.

What info do we provide during change of shift report?

pt status, behaviors, any problems, any meds, ambulation status and any refusals.

What info is on transfer reports?

pt status, purpose of transfer, sx, any precautions such as iso, any open wounds or drains present. Offer opportunity to ask Qs or clarify info.