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SHOPE 25Stack #82639
SHOPE CH. 25 Stack #82639
| Question | Answer |
|---|---|
| Accreditation | Specify guidelines for documentation |
| Acuity Records | Provide a method of determining the hours of care and staff required for a given group of clients. |
| Automated speech recognition (ASR) | AKA voice recognition technology. Could become effective for documentation. |
| Change of shift report | Can be given orally, by audio tape, or during walking planning rounds at pt. bedside. Each method has advantages ie. oral can allow next nurse to ask and clarify things, bedside can get pt. and family involvement. |
| Charting By Exception (CBE) | Used to eliminate redundancy, ensure concise documentation of routine care, emphazise abnormal findings and ID trends of clinical care. |
| Computer-based Patient Care Record (CPCR) | Comprehensive system that uses many components of data collection. Allows nurse to have an instrumental role in development of documentation. |
| Consultations | One professional caregiver gives formal advice about the care of a pt. to another caregiver ie. a nurse consults with a wound care specialist. |
| DAR | Focus Charting: DATA (subjective and objective) ACTION (aka: nursing intervention) and RESPONSE (of the Pt. ie. evaluation) |
| Documentation | Anything written or printed tat is relied on as record or proof for authorized persons. |
| Critical Pathways | multidisciplinary care plans that include pt. problems, key interventions, and expected outcomes w/i a specific time frame. |
| Flow Sheets | Forms that allow nurses to quickly and easily enter assessment data about the pt. ie. vitals, routine repetitive care (meals, weights etc) |
| Graphic User Interface | Not well suited for nursing, ie. touch pads, mouse, icons) |
| Incidence Reports | Report of any event that is not consistent with the routine operation of a health care unit or client. IE. falls, needle sticks etc. |
| Kardex | Portable flip over file that usually have an activity and Tx section and a nursing care plan section. |
| PIE | Progress Note: PROBLEM, INTERVENTION, EVALUATION. The PIE notes are numbered according to pt's problems and resolved problems are dropped from the daily documentation after nurse review. |
| Problem Oriented Medical Record (POMR) | Method of documentation that places emphasis on the pt's problems. |
| Record | Means by which health care team members communicate client needs and progress, individual therapies, content of conferences, client education, and discharge planning. |
| Referrals | An arrangement for services by another care provider. Sometimes must be ok'd by PCP first, usually for seeing a specialist. |
| Reports | Can be oral, written, or audio taped exhanges of info. between caregivers. |
| Residents | Since many individuals will live in long term care for the rest of their lives they are referred to residents rather than clients. |
| SOAP | SUBJECTIVE (what pt. says), OBJECTIVE (what you observe), ASSESSMENT (needs statement and diagnosis), PLAN (what caregiver is going to do) |
| SOAPIE | SOAP with the INTERVENTION and EVALUATION |
| Source Record | Pt. chart is organized so each discipline (ie. nurse, medical, social work) has separate sections in which they record data. Good because you can easily locate each section. |
| Standardized care plans | Based on institution standards of nursing and are preprinted and established guidelines that are used to care for pts who have similar health care problems. |
| Transfer Reports | To promote continuity of care. See pg. 497 for 9 specifications needed |
| Variances | Unexpected outcomes, unmet goals, and interventions not specified w/i the critical care pathway time frame. |
| Accreditation agencies such as what specify guidelines for documentation? | JCAHO |
| Under the prospective payment system, hospital are reimbursed a set dollar amt. by medicare for each what? | Diagnosis related group (DRG) |
| What is a vital aspect of nursing practice? | Documentation |
| Data recorded, reported, or communicated to other health care professionals are what in regards to privacy? | Confidential and must be protected |
| Clients frequently request copies of their medical records. What does the nurse need to understand about this request? | They have the right to read these records |
| Critical pathways are care plans that what? | Include key interventions and expected outcomes. |
| Acuity records are designed to do what? | Determine hours of care needed. |
| In long term care facilities, what is the client referred to as? | Resident |
| What does a telephone order involve? | Clarification, accuracy, and verification. |
| The primary purpose of a client's medical record is to what? | Communicate accurate, timely information about the client |
| This is a correctly charted response according to the 6 guidelines for quality responding. | "Crying. She states that she doesn't want visitors to see her like this." |
| During a change of shift report what happens? | The nurse should ID nursing diagnoses and clarify client priorities. |
| What is an incident report? | Report of event inconsistent with the routine care of a client. |
| If an error is made while recording, what should the nurse do? | Draw a single line through the part that is an error and initial it. |
Created by:
stephanielhope
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