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Documentation NURS 232
Question | Answer |
---|---|
What is CHARTING or DOCUMENTING? | The process of making an entry on a client record. |
Narrative Charting | a traditional part of the source-oriented record. consist of routine notes that include routine care, normal findings, and client problems. |
What should documentation for each encounter with the client include? | ¤ reason for encounter and relevant history ¤ Assessment findings ¤ Plan of care ¤ Date and legible signature of all providers |
What should you do prior to charting | make sure you have the right record. |
Should you leave any spaces before entries or your signature? | No. |
How do you correct an error on a paper chart? | Draw a single line through the error and then date and initial |
when charting clients remarks what should you do? | use quotations. |
Should you chart other nurses or health care staff observations about your client/patient? | No, chart only your own observations. |
Can you alter an entry for someone else? | No, never alter an entry for another person; contact the individual. |
what color ink should you use when charting? | Black |
Can you chart something before you have done it? | No; this can be considered fraudulent. Always chart after you have done the action never before. |
what abbreviations can you use when charting? | only approved abbreviations follow agency p/p. |
What is charting by exclusion | ¤ Usually accomplished by “charting by exception” ¤ Standardized questions are asked, but client responses in the negative are not recorded |
What does charting by exclusion assume? | Assumes all is well unless something is noted. |
What is charting by exclusion based on? | clearly defined standards and criteria. |
What is Flowsheet charting used for? | Used to document specific assessment criteria in an particular format ¤ For example, vital signs, pain intensity scores, intake and output |
What does PIE stand for? | Plan Implement Evaluate |
What does SOAP(IE) stand for? | Subjective Objective Assessment Plan Intervene Evaluate |
What does DAR stand for? | Data Action Response |
What is a shift report? | ¨ Nurse to nurse report when providers change ¨ Nurse to nurse report at change of shift (most facilities have standardized method) ¨ Nurse to provider report for change of condition or for instruction. |
What patient data are you allowed to access? | only the information you need to do you job |
What are the purposes of the client record? | Communication Planning payment care auditing health agencies research education reimbursement Legal documentation Health care analysis |