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Concepts II: Ch. 5
Documentation
| Question/Terms | Answer/Definition |
|---|---|
| Question: While documenting in a client’s chart, the nurse realizes that it is the wrong chart. What should the nurse do? | Answer: Write “mistaken entry” and place initials just above incorrect entry |
| Question: The nurse uses a cheat sheet to jot down pertinent client data while providing care. What should the nurse do with the sheet after documenting all client care? | Answer: Shred the paper |
| Question: A health-care facility uses narrative charting. What should the nurse remember when following this documentation approach? | Answer: It tells the client’s story |
| Question: The nurse caring for residents of a skilled nursing facility wants to quickly check on the latest orders and medications for one client. Where should the nurse locate this information? | Answer: The Kardex |
| Question: The director of a home care agency is scheduling staff to make home visits. Which staff member should visit a client newly admitted to the agency for care? | Answer: Registered nurse (RN) |
| Question: A client received a dose of IV pain meds before shift change. After receiving report, the oncoming nurse notes that the med was not documented, provides another dose, & the client has a respiratory arrest. Who is most liable for this situation? | Answer: The nurse who gave the first dose of medication |
| Question: A hospital’s risk-management team provides the nursing staff with an in-service about incident reports. Which information should be included? | Answer: 1. The client 2. A medication error 3. A client, visitor, or employee injury 4. Out-of-the-ordinary things that happen in a health-care facility |
| Documentation | The act of recording pertinent medical information in a patient’s medical record, which may be handwritten on a paper chart or keyboarded into an electronic medical record (ex: chart, electronic health record/EHR) |
| Continuity of care | Provides members of the health-care team with a more complete picture of each patient |
| Purposes of Documentation | ‒ Continuity of care ‒ Permanent record of care ‒ Accountability ‒ Legal record ‒ Not charted, not done (evidence) |
| Question: Whose Medical Record Is It? | Answer: The hospital or facility |
| Confidentiality | The maintenance of privacy by not sharing with a third party privileged or entrusted information |
| Reasons for incident reports | ‒Med error; patient, visitor or employee injury ‒Safety hazard ‒Failure to respond to an emergency or to perform ordered care ‒Loss of patient’s personal belongings ‒Lack of availability of vital patient care supplies or equipment |
| Question: Which type of documentation form is used to record out-of-the-ordinary occurrences? | Answer: Incident report |
| Types of Medical Records | ‒Source-oriented ‒Problem-oriented |
| Source-oriented medical record | ‒Nurse’s notes ‒Health-care provider’s progress notes ‒Vital signs ‒Rehabilitation therapy ‒Medication administration record ‒Laboratory results ‒X-ray results |
| Problem-oriented medical record | ‒Database ‒Problem list ‒Plan of care ‒Progress notes ‒Encourages collaboration |
| Question: What information would be included in a problem-oriented health record? | Answer: The plan of care |
| Electronic Health Record (EHR) | A record of an individual’s lifetime health information and is easily updated and transferable |
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