EXAM 3- Documentation

Question 1

what should you accurately & completely document routinely as a nurse?

Answer 1

• pt status - including s/s
• nursing care
• medication & treatment administration
• pt response to interventions
• any contact with health care team members concerning significant events (CN, provider, PT, RT, chaplain, etc)

Question 2

what’s the difference between signs & symptoms?

Answer 2

• signs- objective, observable
• symptoms- subjective (what the pt tells you)

Question 3

examples of treatments as nursing interventions

Answer 3

• nursing care
• ambulation
• TCDB
• wounds care

Question 4

ANA standards for documentation

Answer 4

• relevant data- accurately & accessible to the team
• problems & issues- facilitates determination of the expected outcomes/plan
• expected outcomes- measurable goals (decrease pain level from an 8 to a 3)
• plan uses standard language/ terms
• implementation & modifications- including changes of the plan (put the plan into action)
• coordination of care
• results/evaluation
• quality & performance improvement- involved in nursing practice

Question 5

what do formal pt records contain?

Answer 5

• pt identification & demographic data, medication hx
• admission data, discharge plan
• informed consent, pt education, summary of operations
• nursing diagnoses/ problems, care plans, treatment & evaluation, physical assessment
• medical diagnosis, therapeutic orders, diagnostic study
• progress notes

Question 6

what are some purposes of pt records?

Answer 6

• communication
• legal document
• reimbursement compliance
• educaiton/ research
• auditing/ monitoring

Question 7

is the pt chart a persuasive witness/ read as a legal document?

Answer 7

yes
it is a description of the facts at the time

Question 8

why are charts important for communication?

Answer 8

allows for continutity & risk reduction between multi-disciplinary teams

nursing, medicine, PT, etc

Question 9

components of proper documentation

5

Answer 9

• factual
• accurate
• complete
• current
• organized

Question 10

how can you keep your documentation factual?

Answer 10

• objective
• descriptive
• subjective (quotes) from pt or family

just the facts

Question 11

you heard a thud and went to the room & found pt on the floor. what should you document?

A. RN heard a thud and found the pt lying on the floor. it appears the pt has fallen while getting out of bed
B. pt fell in room, event was not observed by staff
C. RN heard a thud, went to the room & found pt lying on floor in room
D. RN found pt on floor and assumes the pt’s family member neglected to help them up

Answer 11

C
always document exacly what happened, NEVER ASSUME

Question 12

how can you document accurately?

Answer 12

• use exact measurements
• clear
• understandable
• standard abbreviations only
• time, date, signature, title
• spelling

Question 13

how can you document completely?

Answer 13

• condition change (onset, duration, location (PQRST), description, precipitating factors, behaviors)
• do not leave blanks (use N/A or lines)
• communication with pt & family (document the ed. you gave, as well as their repsonse (agreement/disagreement))

Question 14

what should the chart ultimately reveal?

Answer 14

• pt needs
• nurse’s interventions
• pt outcome

Question 15

how can you keep your documenting current?

Answer 15

• chart as soon as possible/ at the time of occurrence
• use military time
• never pre-chart (illegal falsiication)

Question 16

how can you keep your documenting organized?

Answer 16

• chronological order
• concise, clear, to the point
• complete sentences not needed

Question 17

terms to avoid in charting

Answer 17

accidentally apparently appears assume confusing could be may be miscalculated mistake somehow unintentionally normal good bad

Question 18

fix the error:

pt has normal lung sounds

Answer 18

lung sounds clear bilaterally

avoid using the word “normal”, be desrcriptive

Question 19

true or false

you can document a pt problem as long as you plan on charting your intervention later on

Answer 19

don’t document a pt problem w/o charting what you did about it

false

Question 20

true or false

altering a pt record is a crime

Answer 20

true

Question 21

true or false

you should avoid writing imprecise descriptions (bed soaked, large amount, etc)

Answer 21

true

Question 22

true or false

you can document what someone else heard, felt, or smelled if they tell you the exact information of the occurrence

Answer 22

don’t chart what someone else heard, felt, or smelled unless the information is critical

use quotations appropriately

false

Question 23

narrative documentation

Answer 23

• written in order of pt exerience
• provides details of pt care, status, activies, nursing interventions, psychosocial context, & response to treatment
• charting by exception

Question 24

PIE

Answer 24

• Problem
• I-ntervention
• Evaluation

nursing focused (rather than medical focused) and eliminates need for separate care plan

Question 25

SOAP/SOAPIE/SOAPIER

Answer 25

* **S**- subjective data * **O**- objective data * **A**- assessment * **P**- plan * **I**- intervention * **E**- evaluation * **R**- revision

Question 26

DAR

Answer 26

* **D**ata * **A**ction * **R**esponse

Question 27

what types of forms would be on a flow sheet?

Answer 27

* vital signs * assessment check list * I/O

Question 28

medication administration records (MAR)

Answer 28

* scheduled meds * unscheduled meds * drug allergies * single order meds

Question 29

kardex

Answer 29

summary of pt needs & care * **pt data** (name, age, marital status, religion, physician, family contact * **medical diagnoses** listed by priority * **allergies** * **medical orders** * **activities permitted** | NOT. a part of permanent record

Question 30

what should you use to write a paper chart?

Answer 30

* blue or black ink * no white out/ erasable pens

Question 31

is the kardex a part of the permanent record?

Answer 31

no

Question 32

SBAR

Answer 32

* **S**ituation * **B**ackground * **A**ssessment * **R**ecommendation

Question 33

what do nurse's notes contain?

Answer 33

* pt condition, problems, & complains * interventions * pt response to interventions * achievement of outcomes * additional assessment * report given/received (nurse's name, time, important information)

Question 34

should you document when you give/ receive report?

Answer 34

YES!! | include the nurse's name, time, any important information

Question 35

components of good documentation

Answer 35

* **who** * **what** (assessment findings, cc, care provided) * **when** (when you provided care) * **where** (where did the event/tx take place) * **how** (how was tx completed, how did pt respond/tolerate) * **outcome** (outcome of procedure, tx) * **follow-up** (what f/u is needed, vitals, pain level, etc) * **accuracy** (exact measurements) * **objective vs subjective data**

Question 36

what should you document when notifying a provider?

Answer 36

* full name of provider * exact time of notification * specific lab result, symptom, or assessment data * provider's response * any orders the provider gives * vitals, observations, nursing interventions * f/u by provider * symptoms & parameters * note your own actions to assist pt * pursue chain of command if provider doesn't answer * record all your actions

Question 37

what should you include when documenting a pt's refusal?

Answer 37

document: * pt refusal * reason for refusal * what you did about it

Question 38

# true or false you should NEVER use labels to describe a pt or their behavior

Answer 38

true

Question 39

# be more desrciptive wound is infected

Answer 39

* skin around wound is red * warm to touch * purulent disharge * pt complains of increased paid x1 day

Question 40

# be more descriptive pt is nervous

Answer 40

pt asked several times about length of hospitalization, discomfort, and time off work

Question 41

what should you document if you question a provider's order?

Answer 41

document that clarification was sought

Question 42

how do you correct an error on a paper chart? on EMR?

Answer 42

* single line through entry, write your initials * EMR: make a new entry, explain the error

Question 43

how should you chart a late entry in a paper chart? EMR?

Answer 43

* **paper**: add entry and title "late entry", record the date/time of the entry & the date/time it should have been made * **EMR**: change date/time & document (this can be tracked/audited)

Question 44

# be more descriptive 1900 pt arrived to ER complaining of stomach pain

Answer 44

include PQRST to describe pain more accurately

Question 45

what % of the most frequent allegations against nurses in medical liability claims deal with documentation?

Answer 45

66%

Question 46

why do nurses commonly have claims made against them concerning documentation?

Answer 46

* **ascence of documentation**- if it wasnt charted, it wasnt done * **timing of documentation**- (late entries) self servind, different that what would ahve been charted at the time of tx