Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
CNA-NIC F25 CH 3.9
Explain guidelines for documentation
| Question | Answer |
|---|---|
| nursing assistants chart (document) | all resident care that they provide , also document observations |
| what is important when documenting | document accurately |
| what does documentation provide | an up to date record of each residents status and care |
| the medical chart is | a legal document |
| documnetation is | legal record of all resident care |
| if something is not documented on the resident chart legally it is | considered not to have been done |
| why is documentation important | for planning residents care |
| guidelines for accurate documentation #1 | Keep all information in the chart confidential |
| guidelines for accurate documentation #2 | Document immediately after care is given. Record your notes carefully. Never record an care before it has been completed |
| guidelines for accurate documentation #3 | Use black ink when documenting by hand. write neatly |
| guidelines for accurate documentation #4 | medical chart may be in electronic or paper form. For paper charts, sign each note you make. Sign your name and title, use the correct date/time. Doc done electronically automatically enters the name of the person recording the info as well as date/time |
| guidelines for accurate documentation #5 | use only facts not opinions when documenting |
| what words should not be used in the chart due to guideline 5 | seems, appears to be, or looks like are not used in charting |
| what is an example of guideline 5 that is an option and should not be charted regarding residents food preferences | the resident doesn't like the food here (is an opinion) |
| what is an example of guideline 5 that is a fact and should be charted regarding residents food preferences | the resident refused her dinner tray, saying the food is to spicy (document exactly what the person has said or what you see, hear, smell or touch) |
| guidelines for accurate documentation #6 | Us e comparisons to describe size instead of words like large or small or medium |
| give an example of using a comparison to provide accurate documentation for describing a spot of blood | there is a dime sized spot of blood on her bandage |
| guidelines for accurate documentation #7 | if you make a mistake when documenting electronically, add a new note with the corrected information following facility policy |
| if documentation is done in paper records, how do you fix a mistake | draw one line through the error. provide correct information, and initial and date the entry. include any other needed information. do not erase what you have wrriten. do not use correction fluid |
| guidelines for accurate documentation #8 | Use only your facilities accepted abbreviations and terms. |
| what will all faculties have | policies and procedures for documenting |
| what should NAs do regarding documentation | following facilities policies and procedures for documenting |
| Some facilities require documentation on | a check off sheet |
| what is another name for a check off sheet | ADL , flow sheet |
| ADL | activities of daily living |
| many abbreviations are derived from | Latin |
| et al. | Latin et allia : means and other things. Only al has a period at the end |
| i.e. | Latin id est: means that is. Both letters have a period |
| e.g. | Latin exempli gratia: means for example. Both letters have a period |
| Besides paper documentation at some facilities what are ways of keeping documentation | documentation is done electronically |
| What are the advantages of using computers | computers can easily store information that can be retrieved when it is needed |
| What is usually faster and more legible than writing documentation by hand | using computers for electronic documentation |
| there is a variety of devices that can be used for electronic documentation | 1.some facilities have a computer in every resident's room (staff input information each time they enter and leave a room) 2.facilities have a laptop, tablet, pocket sized handheld device moves with the staff member from room to room |
| pros of electronic documentation | electronic documentation replaces time consuming paper charting |
| what is still needed | some paperwork may still need to be done even with electronic charting |
| how do people learn how to use electronic documentation/devices | Facilities train staff members how to use electronic devices |
| Even when electronic documentation is required what sort of training is often required | training often includes how to document by hand |
| why is training about paper documentation required even when electronic documentation is preferred | in case there is a system failure. electronic documentation will not work. So paper documentation is used |
| What applies to both electronic and paper charts | legal guidelines |
| General rules for electronic/computer documentation #1 | Change passwords when prompted |
| Guidelines for electronic/computer documentation #2 | Do not share personal passwords or login IDs with anyone. Do not have a coworker enter information for you, even if it is more convenient |
| Guidelines for electronic/computer documentation #3 | Be careful about who can see private or protected health information (PHI) or electronic health records (EHR) on the computer screen while you are working. HIPAA privacy guidelines apply to electronic documentation. |
| Guidelines for electronic/computer documentation #4 | Make sure you are logged into the correct resident's chart before beginning to document. Log out and or exit the resident's chart when finished with documentation. |
| Guidelines for electronic/computer documentation #5 | If the computer software has an autofill feature (automatically completes certain fields that have been entered before) be sure the entries are accurate. Check your entries again before exiting the resident's chart. |
| Guidelines for electronic/computer documentation #6 | Do not print documents unless directed to do so, and shred documents as instructed |
| Guidelines for electronic/computer documentation #7 | Do not send confidential information via email |
| Guidelines for electronic/computer documentation #8 | Log out and exit the web browser when finished with charting or using the computer |
| Guidelines for electronic/computer documentation #9 | Do not access your personal accounts or browse the internet from work computers |
Created by:
user-1830624
Popular Nursing sets