68WM6 Documentation
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| Routine care | Chief complaint; subjective and objective findings; diagnosis; treatment plan; response to treatment.
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| Condition change | Professionals have an obligation to recognize condition change and take action. Can only illustrate this through documentation.
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| The chart is used as a | utilization record
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| Factual, Objective Notations are | What you hear, see, feel, and smell.
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| Tampering | You may be asked whether or not you tampered with the record when the record is requested.
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| A lawyer may ask you this in regards to editing a nursing document in court..... | More likely it is, “Did you alter the record in any way?.” This is much broader.
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| Drug doses | Units vs. a zero (always write out units).
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| Why use leading zero for decimals? | (ensures decimal is recognized).
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| If it is documented, it is assumed to be | accurate
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| Is it okay to document ahead of time? | Never document ahead
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| Grammar and cleanliness are worthwhile: messy notes give an appearance of | messy care.
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| When a patient does not cooperate with medical care what can we do in the patient chart? | Use quotes when possible to illustrate the non-compliant behavior.
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| If a patient wants to leave against medical advice what should you do? | Document every detail and advise the patient of the consequences. If possible, try to get patient to sign refusal of care document.
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| An LVN can only execute what kind of orders? | Written orders
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| Telephone and Verbal orders can only be taken by whom? | RN's
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| Medication orders must include | Medication name.Dose.Route.Frequency.
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| Assessment | a systematic and continuous collection, and communication of pt data
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| Diagnosis | an analysis of pt data to identify patient strengths and health problems identified which independent nursing interventions can prevent or resolve.
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| Planning | the establishment of pt goals to prevent, reduce, or resolve the problems identified in the nursing diagnoses. The nsg dx guides the development pertinent nsg interventions.
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| Implementation | putting into practice the plan of care
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| Evaluation | measurement of the extent to which the patient has achieved the goals specified in the plan of care.
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| Comprehensive Assesment (Complete): | provides baseline patient information which includes Physical examination of all body systems. Appropriate for stable patients.
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| concentration of attention on the part of the body where signs and symptoms are localized or most active in order to determine their significance. | Focused
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| Focused assesments are appropriate for... | critically ill, disoriented, or unable to respond patients.
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| Ongoing Assesment | systematic follow-up is required when problems are identified during a comprehensive or focused assessment.
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| Subjective Information | verbal statements from the patient.
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| Objective | observable and measurable which can be recorded.
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| Primary Source of Information | patient. Collected from patient interview and physical examination.
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| Secondary Source of Information | family members, significant others, health care team, medical records, diagnostic procedures, and nursing literature.
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| Data clustering | process of putting data together in order to identify areas of the patient's problems and strengths. Mixing all your data together like a tasty martini
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| Hierarchy of needs (Maslow's) | individual's basic needs must be meet before higher-level needs can be met.
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| Actual Nursing Diagnosis | a condition that is currently present.
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| Risk | is a clinical judgement that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation.
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| Possible | when a problem is considered feasible.
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