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11 Cards in this Set

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State at least three reasons for maintaining a written and continous health record
To maintain effective communication among all caregivers;
For research and educational purposes; and
To protect against accusations of inadequate or poor nursing care.
Discuss the advantages and disadvantages of both manual and computerized documentation
Advantages of computerized is that the record is centralized, simplified and can be accessed quickly. The disadvantage of computerized is the costs of a system and the training of the staff to use the system.
Manual: disadvantage more likely for handwriting error; more bulky; can be viewed more easily by noncaregivers
List at least four categories of information that are included in the health record
Assessment documents such as medical history or physical
Plans of Care such as physician's orders
Progress records such as flow sheet and progress notes
Plans for continuity of care such as teaching record or discharge summary
Discuss the goal, content, and procedure of writing progress notes.
Reasons to use progress note entry are to establish a baseline of data; enter data at regular intervals; summarize the client's condition; document changes in the client's condition; and document a response to treatment.
The goal of writing a progess note is to summarize the progress of client towards achieving his or her care plan goals. The CONTENT of the progress note is typically written in a narrative , chronoligcal format and can be a summary or narrative of an event or conversation, assessment or activity. The procedure is done hourly, every 2 hours or per event.
Differentiate among the following types of charting in progress notes: narrative, SOAP, SOAPIER, APIE, PIE, DAPE, DARP, DARE, and CBE
Narrative is type of nurses note that documents what happens throughout day chronologically, this type is detailed and time consuming;
Problem Area Charting or focus charting uses:
SOAP Subjective Objective Assessment or analysis Plan
SOAPIER Subjective Objective Assessment Plan Intervention Evaluation Revision
APIE Assessment, Plan, Intervention Evaluation
PIE Plan, Intervention Evaluation
DAPE Data, Assessment, Plan Evaluation
DARP Data Assessment Response Plan
DATE Data, Action, Response, Education
CBE Charting by Exception and uses SOAPIER for progress notes
State the advantages and disadvantages of the following types of documentation: narrative, problem-oriented, discipline area, charting by exception, case management, critical pathyways, and medication administration records
Advantages of Narrative charting is that is detailed and thorough; disadvantage is that is time-consuming
PROBLEM ORIENTED advantage is less time consuming and disadvantage is leaves out pertinent data.
DISCIPLINE AREA advantage is providers from each speciality area can find their own form without having to read notes from other disciplines. Disadvantage is difficult to obtain a holistic view of client
CBE advantage is it list the most common normal and abnormal findings; disadvantage when legal defense is necessary.
CASE MGM advantage is ____; disadvantage not used for client with special or complex needs.
CRITICAL PATHWAYS are same as case management
MEDICATION ADM RECORDS (MARS) advantage is this form is kept separate for easy access; disadvantage is _____
Identify the data that are commonly found on a flow chart
flow sheet/chart documents large amounts of information briefly and concisely by a timeline; includes IO sheets, graphic sheets for vital signs, anesthesia sheets during surgery, routine nursing care, intensive care sheets: weight, vital signs, dietary, neuro checks, restraint observations, postop records, wound care
State eight guidelines that are generally accepted for documentation
document what you see; be specific; use direct quote; be prompt; be clear and concise; record all relevant information, respect confidentiality; record documentation errors
Practice using descriptive terms, abbreviations, and acronyms commonly used in charting
ROS review of systems
R/T related to RX prescription
STAT immediately S&S signs and symptons "s with line on top" means without TX treatment TID three times a day NOP nothing by mouth >greater than<less than AMI acute myocardial infarction CA cancer CHF congestive heart failure PE pulmonary emboli PAGE 393
Identify and differentiate the regulations and method of documenting for the following: an error that occurred regarding care for a client.
using an eraser or white out is illegal on a health record. If error is made cross out with single line, enclose in parentheses and write ERROR and your initials next to it or RIE recorded in error; then record the correct statement
Describe the process and content of reporting information to nurses. Discuss how this type of report differs from communicating to other members of the healthcare team.
you must "report off" to a nurse several times a day; you summarize the activites and conditions of the client when you go on break or the end of your shift. Change-of-shift reporting. Walking rounds is when you move from client to client giving them pertinent information. Reporting is an oral method of communicating that is timely, precise and accurate.