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68WM6 Documentation

Routine care Chief complaint; subjective and objective findings; diagnosis; treatment plan; response to treatment.
Condition change Professionals have an obligation to recognize condition change and take action. Can only illustrate this through documentation.
The chart is used as a utilization record
Factual, Objective Notations are What you hear, see, feel, and smell.
Tampering You may be asked whether or not you tampered with the record when the record is requested.
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.
Drug doses Units vs. a zero (always write out units).
Why use leading zero for decimals? (ensures decimal is recognized).
If it is documented, it is assumed to be accurate
Is it okay to document ahead of time? Never document ahead
Grammar and cleanliness are worthwhile: messy notes give an appearance of messy care.
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.
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.
An LVN can only execute what kind of orders? Written orders
Telephone and Verbal orders can only be taken by whom? RN's
Medication orders must include Medication name.Dose.Route.Frequency.
Assessment a systematic and continuous collection, and communication of pt data
Diagnosis an analysis of pt data to identify patient strengths and health problems identified which independent nursing interventions can prevent or resolve.
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.
Implementation putting into practice the plan of care
Evaluation measurement of the extent to which the patient has achieved the goals specified in the plan of care.
Comprehensive Assesment (Complete): provides baseline patient information which includes Physical examination of all body systems. Appropriate for stable patients.
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
Focused assesments are appropriate for... critically ill, disoriented, or unable to respond patients.
Ongoing Assesment systematic follow-up is required when problems are identified during a comprehensive or focused assessment.
Subjective Information verbal statements from the patient.
Objective observable and measurable which can be recorded.
Primary Source of Information patient. Collected from patient interview and physical examination.
Secondary Source of Information family members, significant others, health care team, medical records, diagnostic procedures, and nursing literature.
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
Hierarchy of needs (Maslow's) individual's basic needs must be meet before higher-level needs can be met.
Actual Nursing Diagnosis a condition that is currently present.
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.
Possible when a problem is considered feasible.
Created by: 670441040