Lecture 2 Documentation

Question 1

Documentation

Answer 1

• Detailed account of quality of care
• Communicate pt info accurately and timely effective manner
• Didn’t chart it, didn’t happen
• Record = Chart
• Confidentiality

Question 2

Confidentiality

Answer 2

Legal and Ethical obligations

Protect info:

• Don’t leave it in a public area
• Sign off the computer
• Don’t be yapping around
• Don’t leave anything that has your patient’s info
• Don’t email client info
• Shred all the proper information don’t take anything home
• Don’t speak to anyone over the phone
• Don’t post anything on social media

Health information privacy act (HIPA)- provincial legislation

Question 3

Health information privacy act (HIPA)

Answer 3

-Came about in 1997
-Proclaimed in court in 2003
-Protecting the privacy of your health information
•States the rights of individuals and obligations of workers in a health system remains confidential

Question 4

Purpose of a Health Record (chart):

Answer 4

More then just communication and care planning

• Legal Document
• Education (using data for audits)
• Funding and Resource Management
• Research
• Quality Review

Question 5

Health Records contain the following:

Answer 5

o	Patient demographics
o	Admission nursing database
o	Nursing care plans
o	Nursing notes
o	Medical history
o	Medical diagnosis
o	Orders
o	Progress notes
o	Test reports
o	Operative notes
o	Discharge plan and summary

Question 6

Types of Records

Answer 6

Source orientated Record

Problem Orientated

Question 7

Source Orientated Record

Answer 7

• Organised under separate disciplines
• Each discipline has section
• Not chronological
• Must go to different sources to read same topic
• Repetitive

Question 8

Problem Orientated

Answer 8

• data organized by pt problems
• medically based format
• Health Care members contribute to a single list of identified pt problems:
• chronically ill pt
• Pt with many problems
• All members take care of same problem
• Comprehensive individualized care
• Issue: Multiple problems with the same symptoms
• Problem focused

Question 9

Ways to document nursing care

Answer 9

• Narrative (source)
• SOAP (problem)
• PIE (problem)
• Focus Charting (problem)
• Chart by exception (problem)
• Case management

Question 10

Narrative (source)

Answer 10

• Story
• time consuming
• Lots of info
• What is relevant
• Client Reponses
• Oriented = Person place and time
• See Mar = see medication record
• O/M = Observation and measurement

Question 11

SOAP (problem)

Answer 11

Subjective (pt remarks)

Objective (vital signs)

Assessment (nursing diagnosis)

Plan (resolution)

Question 12

SOAPIER (problem)

Answer 12

Subjective
Objective
Assessment
Plan
Intervention
Revision

Question 13

PIE

Answer 13

Problem (diagnosis)
Intervention
Evaluation

Question 14

Focus Charting (problem)

Answer 14

Based on pt Concerns

Uses DAR:
Data
action
Response

Pt Centered
Used for narrative
Flow chart

Question 15

Chart by exception (problem)

Answer 15

Document deviations from the normal (saves time)

CBE

Based on set standards that have been met

Question 16

Case management

Answer 16

Critical pathway = care maps

Multidisciplinary

Efficient

Computerized

Tailored to specific disease

Question 17

Admission Database

Answer 17

Complete initial nursing assessment of pt on admission

Question 18

Standardized Care plan:

Answer 18

Standardized form with some individualization

Question 19

Kardex (temp record)

Answer 19

Basic pt care summary

Question 20

Flowsheets and graphic records:

Answer 20

Records for quick data entry

Question 21

Discharge Summary:

Answer 21

Includes discharge info and instructions

Question 22

Incident Reports

Answer 22

Involved in or witness
near miss
no blame 
-med errors
-incidents

Question 23

What do we document:

Answer 23

• Care that you have provided
• Patient status (vital signs)
• Changes in patient status
• Medication administration

Question 24

Documentation guidelines

Answer 24

•	Date and time (24-hour clock)
•	Be timely
•	Use logical order
•	Meet set standards 
•	Write legibly in blue or black ink
•	Use accepted Abbreviations/symbols
•	Spelling and grammar
•	Sign all entries
o	Name and title: S. Akinfiresoye, UofS NS
•	Stick to the facts
o	Descriptive and objective
•	Be current and organized
o	Timely and well laid out
•	Be compliant with standards
o	Documenting what is done
•	Be accurate, specific, complete

Question 25

DO NOT:

Answer 25

• Never erase or use whiteout • Janet IV was displaced after her shower is in situ. Error O, Akinfiresoye NS Sept 13/18 • Never leave blank spaces in your notes • Only chart your own actions – if you did not give the med you do not sign off on it • DO not “prechart” • Begin with date and time, end with signature and role (ie O. Akinfiresoye, UofS, NS)