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NRS 104 Lecture 3
Documentation Defined
| Question | Answer |
|---|---|
| Documentation Defined | Communication; Written evidence of: Interactions between & among health professionals, families & health care organizations; Administration of tests, procedures, treatments & client education; Results or client response to diagnostic tests & nursing inter |
| Purposes of Client Records | Communication; Education; Research; Legal & Practice Standards |
| Communication | 1.)Accurate data for plan of care; 2.) Communication between health care providers 3.)Written evidence of care & client’s response; 4.) Compliance with professional practice (ANA); 5.) Compliance with accreditation criteria (JCAHO); 6.) Documentation for |
| Legal & Practice Standards | Legal document; Institution or facility is owner of medical record; ANA Standards; Nurse Practice Act; JCAHO standards |
| Maintaining Confidentiality | HIPA guidelines; Computer guidelines; Medical record guidelines |
| Narrative Charting | Narrative Charting; Source-Oriented Charting- Date, Time, Notes (8/23/06 1100 Dressing changed on LLL. 4x4 gauze and packing removed with moderate amt of yellow, foul smelling drainage. Area surrounding wound red, warm and tender. Wound measures 6x |
| Types of Documentation | Problem-Oriented Charting (POMR); Problem Oriented Record (POR) For POMR & POM, only problems are documented. SOAP, SOAPIE, SOAPIER – Subjective Info., Objective Info., Assessment, Plan – Intervention, Evaluation, Revision |
| Types of Documentation (cont’d) | Problems, interventions, evaluation (PIE); Focus charting (DAR) (Data, Axn, Response) |
| PIE Charting | |
| Types of Documentation (cont’d) | Charting by exception (CBE)Computerized charting |
| Critical Pathway/Appendectomy | |
| Long-Term Care Documentation | Minimum data sets: Skilled vs. intermediate careFlow sheets: Graphic record, Skin assessment, Bowel movements |
| Standardized Forms | Nursing care plans; Kardexes; Flow sheets; Progress notes; Nursing discharge/Referral summaries |
| “Do’s” of Charting | Date, time each entry; Document change in client’s condition and intervention taken; Review previous documentation; Chart objectively; Document client teaching; Chart clearly and precisely |
| “Do Nots” of Charting | Don’t scratch out mistake, draw one line through and initial; Don’t leave blank lines; Don’t chart in advance; Don’t be vague; Don’t chart for someone else |
| Abbreviations to avoid | u; dc; wc; Pt, Pt; Po; Q, qid qod; 0.06mL not 0.060mL |
| Change-of-Shift Reports | May be recorded or verbal; Include basic client information; Include base line data and any changes; IV status, location, fluids and rate; Neuro, cardiac and respiratory status; Abnormal lab values or scheduled tests |
| Writing Orders | Telephone orders ; Verbal orders Always repeat orders and accurately get the name of the person giving the orderInclude third party name if receiving order from office personnel |
Created by:
jenbj
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