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nur documentation
nursing documentation
| Question | Answer |
|---|---|
| 8 reasons for documentation | communication, education, assessments & planning, research, auditing, legal documentation, agency accreditation, reimbursement |
| flow sheets | repetitive documentation, quick reference, faster documentation, MAR, nursing care for 24 hours, VS |
| narrative charting | summary of routine care, normal findings, patient problems. chronological order. |
| charting sequence | describe the assessment of patient, nursing interventions, evaluation |
| charting | concise, accurate, factual, written documentation and communication of occurrences and situations pertaining to a patient |
| federal statutes | medicare, medicaid |
| state statutes | nurse practice act, department of health |
| JCAHO | joint commission on accreditation of healthcare organizations |
| problem oriented medical record | data is arranged according to the problem the patient rather than the source of the information |
| charting by exception | documentation system in which only abnormal or significant findings or exceptions to norms are recorded |
| computerized charting | use computers to store patients database, add new data, create and revise care plans and document patients progress |
| the following information should be charted | doctor visit, calls to MD, stat meds, prn meds, treatments, refusal of meds or treatments |
| charting and the nursing process | nursing process provides the framework for decision making throughout all phases of nursing care. relate the nursing process and charting in the patient record |
| standard of care | detailed guidelines that represent the predicted care indicated in a situation, define professional practice and nursing care, care/critical pathways |
| source orientated medical records | each person or department makes notation in a separate section of patient chart, information about a problem is distributed throughout the record |
| nursing kardex | medical diagnosis, info needed for daily care, accessible, written plan of care, diet, activity, orders, saftey precautions, scheduled tests and procedures |
Created by:
kamia2010
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