Chapter 20 - Documentation

Verbal orders should always be documented as...

VO with the date, time, and name and credentials of the HC provider who gave the orders

A nurse administrator is participating in an audit that has the goal of creating a quality improvement plan. Which organization will the nurse be reporting to?

JCHO

Describe Narrative Notes Charting.

i. Progress notes written by nurses in a source-oriented record ii. Address routine care, patient data, and patient problems identified in care plan iii. Include description of status of the problem, related nursing interventions, patient responses to interventions, needed revisions to care plan

Describe Focus Charting.

i. Purpose is to bring the focus of care back to patient and their concerns ii. Incorporates many aspects of patient/patient care instead of problem list or list of nursing/medical diagnoses iii. Focus may be a patient strength, problem, or need iv. Advantage: ease of charting because each note does not need to incorporate data, action, and response

Describe Charting by Exception (CBE) Charting.

i. Shorthand method of documenting normal findings ii. Based on standardized normals, standards of practice, and predetermined criteria for assessments and interventions iii. Significant exceptions to the predefined norms are only documented in detail iv. Common in EHRs v. If nothing is documented, the patient's status is assumed to match the normal findings

Describe SOAP Charting.

i. Subjective, objective, assessment, plan ii. Used to organize entries in the progress notes of the problem-oriented medical record iii. Some nurses think it focuses too narrowly on problems and prefer to return to traditional narrative format

How do you report continuity of care?

a. Change of shift/handoff reports b. Written or verbal, best done at bedside c. Oncoming and outgoing nurses assess patient together, review med records and health care provider's orders and nursing orders, establish patient goals for the shift

What is ISBAR and what is its purpose?

-Identify, Situation, Background, Assessment, Recommendation, (Read Back) -Ensures patient safety -Communication technique that is a framework for communication between members of the health care team and a patient's condition -Allows for easy and focused way to set expectations for what will be communicated and how

Assessment, Intervention, Response, Action (AIRA)

1. Chart assessment data observed, interventions you performed, the patient's response to interventions and any actions you took based on the response 2. Can also be Data, Action, Response, Action (DARA) 3. Part of Narrative Notes.

How is patient confidentiality violated?

a. Displaying info on a screen that is viewable by unauthorized users b. Sending confidential email messages via public networks (i.e. internet) where they can be read by unauthorized users c. Sharing printers among units with differing functions and information d. Discarded copies of patient health info in trash cans e. Holding convos vulnerable to eavesdropping outsiders with scanning equipment f. Faxing confidential information to unauthorized persons g. Sending confidential messages that can be overheard on the pager

How to ensure accurate charting?

a. Read back verbal orders b. Be complete, concise, current, and factual c. Record patient findings versus your interpretation d. Refrain from copy/paste e. Document in a timely manner f. Ensure you have correct chart

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

a. interpretation of data