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Chapter 9 Docum.

Fundamentals - Documentation

What is collections of information about a person's health, the care provided by health practitioners, and the client's progress? Medical record
What are the 7 uses of the medical record? 1.permanent record 2. sharing info 3. quality assurance 4.accrediation 5. reimbursement 6.education & research 7.legal evidence
Accrediation is done by who? Joint Commission
What are the 2 types of client records? 1.source-oriented records 2.problem-oriented records
What are the 4 major components of problem-oriented records? 1.database 2.problem list 3.plan of care 4.progress notes
What are the 6 methods of charting? 1.Narrative 2.SOAP 3.Focus 4.PIE 5.Charting by exception 6.Computerized
What method of charting generally uses source-oriented records and involves writing information about client & client care in chronological order? Narrative Charting
What method of charting is more likely to be used in a problem-oriented record? SOAP Charting
What does SOAP stand for? S= Subjective data; O= Objective data; A= Analysis of the data; P= plan of care
Can a medical record be tampered with? Why or why not? No because it is a legal document.
What does HIPAA stand for? Health Insurance Portability and Accountability Act
What method of charting is a modified form of SOAP charting? Focus Charting
What method of charting also follows a DAR model? What does DAR stand for? Focus Charting; D=data, A=action, R=response
What method of charting records the client's progress under the headings of problems, intervention, and evaluation? PIE Charting
What documentation or method of charting is when a nurse charts only abnormal findings or care that deviates from the standard? Charting by exception
What documentation is done electronically and is the most efficient for nurses when documenting at the point of care or bedside? Computerized Charting
What are exemptions when agencies can release private health information without the client's prior authorization? beneficial disclosures
What must you do when charting subjective data or what the client says he/she feels? Always use quotation marks around the statement the patient/client makes about they feel or what they say.
What is the #1 way for a nurse to protect his/her self from a malpractice lawsuit? Good documentation
JCAHO stands for? Joint Commission on Accrediation of Healthcare Organization
What are the components of a medical record? Person's health information, care provided by health practitioner, client's progress, plan of care, medication administration record (MAR), laboratory/diagnostic reports
If you forget to document at the moment you complete a task/care for your patient you must do what? You must enter it as a LATE ENTRY!
When making a mistake in documenting in a patient's chart what must you do? MArk through it with only one line and initial it.
If something happens to your patient or something like a reaction to a medication, what must you do? Contact family of the patient.
When taking a physician's order what important thing MUST you do? Read and clarify the order that the physician gave you and document that you read back and it was clarified.
What is a quick reference for current information about the client and his or her care? Kardex
What is a form of documentation in which a nurse indicates with initials the performance of a routine task? Checklists
What does the Joint Commission's standards require that the record show evidence of? A plan of care
What is the form of documentation with sections for recording frequently repeated assessment data? Flow Sheet
What are walking rounds? Giving the report in a client's presence with the oncoming shift nurse.
NKA no known allergies
NSS normal saline solution
OOB out of bed
a.c. before meals
p.c. after meals
stat immediately
via by way of
t.i.d three times a day
b.i.d. twice a day
BRP bathroom privileges
ED emergency department
BM bowel movement
NPO nothing by mouth
I & O intake and output
et and
c/o complains of
CCU coronary care unit
ad lib as desired
AMA against medical advice
po by mouth
UA urinalysis
WNL within normal limits
WC wheelchair
NANDA North American Nursing Diagnosis Association
MAR medication administration record
What are the 3 extended care facilities? 1.skilled nursing facilities 2.intermediate care facilities 3.basic care facilities
MDS minimum data set
Created by: CrissyEllen