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Documentation TAS
Documentation NP1, Test 4
| Question | Answer |
|---|---|
| T or F. Shift change report is most effective when a detailed note is left for the next nurse. | False. Shift change report is most effective face to face. |
| 3 purposes for shift change report | 1. Ensure continuity of care 2. Discuss progress towards goals, problem solve 3. Provide vital info to oncoming nurse to plan and prioritize care |
| What is the most important skill when giving/receiving shift change report? | PRIORITIZE |
| 3 characteristics of an effective shift change report | 1. Follows specific sequence 2. Identifies significant changes in condition and current plan to address change 3. Provides concise details |
| What other issues are relevant to shift change report? | 1. Psychosocial data 2. Info about admissions, discharges, transfers 3. Priorities of care |
| T or F. If a nurse arrives early to work, the best use of his/her time is to get a head start rounding his/her patients instead of waiting for report. | False. A nurse cannot give care if report has not been received. |
| What are five characteristics of good health care records? | 1. Date and time for all recordings 2. Appropriate documenting timing 3. Legible 4. Correct spelling 5. Signature |
| Name the nine purposes of health care record. | 1. Communication 2. Planning client care 3. Auditing 4. Research 5. Education 6. Reimbursement 7. Legal documentation 8. Record can be subpoenaed 9. Health care analysis |
| T or F. Be sure to see your patient some time before the end of your shift. | False. Nurses should lay eyes on their patients as soon as possible. |
| A nurse is charting when an error is made. What should the nurse do? | Cross through incorrect content with one line, then initial. |
| The client is slurring when speaking, but the previous nurse charted clear speech ten minutes before. Since the last documentation was done less than two hours ago, the nurse may wait until two hours have passed before documenting the change. T or F. | False. Changes in client condition should be reported in a timely fashion, with priority on safety. |
| There is no need to read previous nursing notes, as they do not deal with the client's current status. T or F. | False. It is good nursing practice to read previous nursing notes. |
| The client has had 2+ radial pulses bilaterally every four hours for the last 48 hours. The nurse may document 2+ radial pulses bilaterally because the left radial pulse is 2+, so the right radial pulse is probably the same. T or F. | False. ONLY factual information may be documented. |
| Teaching does not need to be documented by the nurse as long as the teaching done is common practice on the assigned unit. T or F. | False. All teaching done by a nurse must be documented. |
| All of client's actual words must be put in "quotes" when documenting. T or F. | True |
| How a client responds to an intervention is not important when documenting. T or F. | False. Clients responses must be documented for evaluation of the efficiency of the intervention. |
| A nurse need only review his/her documentation if there is enough time. T or F. | False. Nurses should always review their nursing notes to ensure clarity and accuracy. |
| If an area does not apply to your clients, leave that area blank. T or F. | False. Never leave empty blanks when documenting. |
| Chart all actions you plan to accomplish within the next hour. T or F. | False. Never chart in advance. |
| Do not use vague terms when documenting. T or F. | True. Be as detailed as possible. |
| In order to relieve some of the strain on fellow nurses, help catch up the charting of busy nurses in your free time. T or F. | False. Do not chart for someone else. |
| When manually charting, white-out is permissible for correcting mistakes. T or F. | False. Mistakes should be crossed through with one line and initialed. |
| The best nursing practice is to chart according to your perceptions about the client. T or F. | False. Do not use bias or perceptions in charting. |
| What are the three principles for adhering to charting legal guidelines. | 1. Accuracy 2. Integrity 3. Respect HIPAA |
| Name the four areas of record confidentiality that must be maintained. | 1. Written communication 2. Computer Information 3. Verbal communication 4. Student guidelines |
| Computer documentation is preferred since there are virtually no drawbacks. T or F. | False. Computer documentation has both pros and cons. p255 Kozier |
| What is a problem oriented record? | Documentation method that permits analytical focus on identified client problems. |
| Name the four parts of a problem oriented record. | 1. Database 2. Problem list 3. Plan of care 4. Progress note |
| What are the advantages to problem oriented records? | 1. team collaborates to create plan 2. Provides quick identification of recognized problems |
| What are the disadvantages to problem oriented records? | 1. Charting may be lengthy and redundant 2. Problem list may not be kept up to date |
| What are the two types of source oriented records? | 1. Traditional 2. Narrative |
| What is a traditional source oriented record? | Each department has a separate section of the record |
| What is a narrative source oriented record? | Typical nursing note including routine care and normal findings |
| What does SOAPIER stand for? | Subjective, Objective, Assessment, Plan, Intervention, Evaluation and Revision |
| Subjective data | what the client says, in quotes |
| Objective data | what you observed or measured |
| Assessment | interpretation, conclusion, diagnosis, problem OR progress towards goals |
| Plan | What will be done about the problem |
| Intervention | Actions taken during the shift |
| Evaluation | How did client respond to intervention |
| Revision | Changes made to care plan |
| How does the Nursing Process apply to the SOAP method? | S and O is data collected while assessing the client, A is the nursing diagnosis, P is planning, I is implementation, and E is evaluation |
| What does APIE stand for? | A is assessment (includes subjective and objective data), P is planning, I is intervention, and E is evaluation |
| What is focus charting? | focus of care is client concerns and strengths |
| What is the main type of focus charting? | DARP charting |
| The focus in focus charting can be... | a condition, a nursing diagnosis, a behavior, a sign or symptom, an acute change in the client's condition, or a client strength |
| What does DARP stand for? | Data, Action, Response, Plan |
| What are the three columns in a typical focus note? | 1. Date and time 2. Focus 3. Progress note |
| Define Charting By Exception. | A documentation system in which only significant findings or deviations from norms are recorded |
| What are the three important components to charting by exception? | 1. Flow sheets 2. Standards of nursing care 3. Bedside access to charts |
| Name four advantages to charting by exception. | 1. Eliminates lengthy repetitive notes 2. Flow sheets for specific entities 3. Reports changes in client condition 4. Easier to read and pick out problems |
| Name three disadvantages to charting by exception. | 1. Makes some nurses uncomfortable 2. Must fill in all blanks with N/A 3. Must know normal standards of care for health care organization |
| What are four forms that have a specific focus. | 1. Skin assessment 2. Pain management flow sheet 3. Incident report 4. Critical pathways |
| With critical pathways, what is a variance? | A goal that is not met |
| What case management aspects apply to critical pathways? | !. Length of stay is predetermined 2. Based on medical diagnosis 3. Interventions 4. Outcomes |
| Criteria for critical pathways covers what 4 areas. | 1. Criteria for length of stay 2. Criteria for expected outcomes 3. Criteria for specific interventions Documentation of client's progress and/or variance towards goals outcomes |
| What are the three keys to quality professional communications. | 1. Accurately describe what you observe 2. Use nursing process to ensure that problems addressed systematically 3. Follow agency guidelines |
| Name four ways to improve and enhance documentation. | 1. Read documentation 2. Use rating scales and abbreviations approved by institution 3. Keep up with medication error prevention 4. Audit your own charts |
Created by:
tiffiny090180
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