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Found of Nursin Ch.7

Documentation

QuestionAnswer
The person who is appointed to examine patients charts and health records to assess quality of care is known as ______________. Auditors
The ___________is a system used to consolidate patient orders and care needs in a centralized, concise way. Kardex (or Rand).
The five basic purposes of written patient records are: 1) Written Communication 2) Permanent record for accountability 3) Legal Record of Care 4) Teaching 5) Research and Data Collection
How does home health care documentation relate to reimbursement? Documentation provides the justification for reimbursement because nurses have to document all of their services for payment (e.g., direct skilled care, patient instructions, skilled observations, and evaluation visits).
A system that is used by medicare for reimbursement of patient care services is ____. Diagnosis-related group.
The most accurate definition of the patient's chart is : A legal record used to meet the many demands of the health system.
What is the purpose of an incident report? A record of any event that is not consistent with the routine operation of a health care unit or the routine care of a patient. THIS INFORMATION HELPS THE FACILITY RISH MANAGER AND UNIT MANAGERS PREVENT FUTURE PROBLEMS THROUGH EDUCATION AND OTHER MEASURES
An incident report is included as part of a person's medical record. True or False False.
What is the relationship between Kardex and the patient's chart? The Kardex contains cumulative information based on the information required for care from the patients chart in a quick reference format at the nurse's station.
What are the advantages of computer documentation? 1. eliminate repetitive entries 2. freedom to access the database. 3. Allows for quick interaction between various departments (lab, dr, pharmacy, billing, etc. 4. Easy to transfer as it is electronic.
What are the disadvantages of computer documentation? 1. programs need to be kept up to date with systems. 2. Training of personnel can take some time. 3. May use a unique language for that specific agency on that computer system. 4. Possible confidentiality concerns.
Focus charting contains ___________ and ___________. Nursing action and patient response.
Charting by exception: decreases the time needed to complete the nurse's notes.
What type of charting format usually requires the most time to complete? Narrative
What type of charting format most reflects the nursing process? Focus
What documentation is included in the "P" when using the PIE method of charting? Problem List
The POMR is divided into which four major sections? Database, problem list, (care) plan, and progress notes.
The problem oriented medical record does what? It uses a patient problem list as an index for chart documentation.
The charting format most commonly used for documentation of clinical pathways is _______________. Charting by Exception (CBE).
What are the basic guidelines for charting? Correct spelling, punctuation, and grammar. Good penmanship Information is clear, concise, and accurate.
Confidentiality of a patient's medical record is guaranteed by? HIPAA
Who owns a medical record/Health Care Record? Institution or Physician
Patients have immediate access to their medical record. True or False False. The only exception is VA hospitals.
What happens when an error is made by the nurse in charting? A line is drawn through the error and initialed, and then the nurse continues with the charting.
Confidentiality is most often maintained with use of computer charting through the: assignment of individual passwords
Inadequate documentation that is commonly involved in cases of malpractice includes: 1. documenting incorrect data 2. charting nursing actions in advance 3. charting incorrect times at which events occurred. 4. failing to record verbal orders or failing to havbe them signed.
When documenting care and observations in a patient record: Use of approved medical terms and abbreviations are permitted.
patient healt care records are: concise, legal records of all care given and responses.
When the POMR method is used for documentation: the charting format is SOAPE or SOAPIER
The nurse is usint the SOAPE method to chart. In this method the S stands for subjective information the patient states or feels.
When charting the nurse should chart as soon and as often as necessary.
Understanding that health care personnel must respect the confidentiality of patients records, the nurse should: read charts only for a professional reason.
The use of computers in the hospital by nurses: can save on charting time once nurses are comfortable using computers.
When completing and incident report, the nurse is aware that it is necessary to: Document facts regarding the incident.
Charting by exception documents those conditions, interventions, or outcomes outside the norm. True or False True
What is a recommended guideline for charting? Have the patient names and identification number on every sheet.
The 24-hour patient care record-keeping system is useful in consolidating the nursing record.
Acuity charting requires what? Staff to document their interventions.
Which accredidation agency specifies guidelines for documentation? The Joint Commission (TJC)
When comparing documentation for acute care in hospitals with documentation for long-term care, majore diferences are related to : The prospective payment system determing the standards for reimbursement.
What kind of documentation method describes occurences in chronological order? Narrative documentation
Standards and policies regarding documentation in long-term care facilities is guided by _______. MDS
The government reimburses agencies for health care costs incurred by Medicare and medicaid recipients based on ____________. Diagnosis-related groups.
Auditors people apointed to examine a patients charts and health records to assess quality of care.
Chart (Health Care Record) Legal record that is used to meet many demands of the health accrfedidation, medical insurance, and legal systems.
Charting Process of recording information on a patients chart.
Chart by Exception (CBE) Recording only new data or changes in a patient status or care.
Database Large store or bank of information.
Diagnosis Related Group (DRG) System that classifies patients by age, diagnoses, and surgical categories.
Documenting Process of adding information to the chart, usually at prescribed intervals.
Kardex (or RAND) Card system used to consolidate patient orders and care needs in a centralized, concise way.
Narrative Charting Nurse documents in story form all pertinent patient observations, care, and responses.
Nomenclature A classified system of technical or scientific names and terminology.
Nursing Care Plan Plan care based on Nursing assesment and nursing diagnosis
Nursing notes Form on the patients chart on which nurses record their observations, care given, and the patients responses.
Peer Review an appraisa by professional co-workers of equal status.
Problem List Prioritized master list of the patients active, inactive, temporary, and at-rishk medical or other problems.
Problem-Oriented Medical Record (POMR) Method of recording data about the health status of a patient in a problem-solving system.
Quality Assurance, Assesment, and improvement An evaluation of services provided ana the results acheives as compared with accepted standards.
Recording Process of adding written information to the chart, usually at prescribed intervals.
SOAPIER USED IN POMR charting S - subjective O - Objective A - Assesment P - Plan I - Intervention E - Evaluation R - Revision
Traditional (block) chart Traditional chart broken down into sections or blocks.
Created by: losmica