Ch. 15 Documentation

Question 1

Electronic health record (EHR)

Answer 1

• Enhances communication among health care providers and thus patient safety
• Helps to avoid admissions and delays in care

Question 2

Personal Information Protection and Electronic Documents Act (PIPEDA)

Answer 2

federal organization

-applies to all commercial organizations not just health care

Question 3

Records or chart:

Answer 3

Confidential permanent legal document

Question 4

Reports:

Answer 4

Oral, written, audio-recorded exchange of information

Question 5

Consultations:

Answer 5

A professional caregiver providing formal advice to another caregiver

Question 6

Referrals:

Answer 6

Arrangement for services by another care provider

Question 7

Narrative

Answer 7

The traditional method (story-like format)

Question 8

Problem-Oriented Medical Record

Answer 8

Database
Problem list
Care plan
Progress notes

Question 9

SOAP

SOAPIE

Answer 9

Subjective data—objective data—assessment—plan

Subjective data—objective data—assessment—plan—intervention—evaluation

Question 10

PIE

Answer 10

Problem—intervention—evaluation

Question 11

Focus charting (DAR)

Answer 11

Data—action—response

Question 12

Source records

Answer 12

A separate section for each discipline
- nursing will have it’s own section, doctors another. It’s easy to find your own section but the details could be in many dif sections so hard to find the information

Question 13

Charting by exception (CBE)

Answer 13

Focuses on documenting deviations

- only chart when something unusual happens . If everything is going as usual then no note is written

Question 14

Variance

Answer 14

is present when the activities on the critical pathway are not completed as predicted or the patient dies not meet the expected outcomes

Question 15

Standardized care plans

Answer 15

std guidelines to treat patients with similar diagnosis. It doesn’t leave a lot of room for patients unique needs.

Question 16

Acuity ratings

Answer 16

• determine the hours of care and number of staff required for a given group of patients every shift or every 24 hours.
• For example, in an acuity system, bathing patients is classified from 1 (very independent) to 5 (totally dependent in all aspects of care).
• There will be a lower staff-patient ratio in a med nursing situation then in a nursing home

Question 17

Change-of-shift reports

Answer 17

Transfer of accountability practice guidelines
Background information
Assessment
Nursing diagnosis
Teaching plan
Treatments
Family information
Discharge plan
Priority needs

Question 18

(I-SBAR-R) technique

Answer 18

Identification—situation—background—assessment—recommendation—read back

Question 19

Health informatics

Answer 19

The combination of clinical practice, information management/information technology, and management practices to achieve better health

Question 20

Informatics

Answer 20

Not just computer competency

Ability to use evolving methods of discovering, retrieving, and using information in practice

Question 21

Critical Thinking

Answer 21

• Recognition that an issue exists, analyzing information, evaluating information, and drawing conclusions
• Use of evidence-informed knowledge and the clinical decision-making process

Question 22

Inference:

Answer 22

making education guesses. Looking at the meaning and patterns and make an guess

Question 23

Basic critical thinking

Answer 23

following procedure step by step without adjusting to patients unique needs. No thinking ot processing. Can be memorized. Ex. Cather insertion

Question 24

Complex critical thinking:

Answer 24

Nurse learns that a problem may have more than 1 or conflicting solutions. Ex. Diabetse, normally we’d give short acting insulin 30min before a meal. Maybe in this case their blood sugar is 3.5 and they’re not planning on eating a meal.

Question 25

Commitment

Answer 25

you make a decision and you stand by it

Question 26

Critical Thinking Synthesis

Answer 26

A reasoning process by which you use knowledge, reflect on previous experience, and integrate professional practice standards to provide competent, ethical nursing care