Define Health care documentation Show Any written or electronically generated information about a patient that describes the patient, the patient's health, and the care and services provided, including the dates of care What is the primary purpose of health care documentation and recording systems? The facilitation of information flow that supports the continuity, quality, and safety of care Who are standards for documentation established by? Each health care organization's policies and procedures Should be in agreement with The Joint Commission's standards and elements of performance What does the ANA's model for high-quality nursing documentation reflect and include? Reflect the nursing process Includes: Accuracy Relevance Auditability Thoughtfulness Timeliness Retreivability Define medical record A document with comprehensive information about a patient's health care encounter, as well as demographics administrative and clinical data What serves as the major communication tool between staff members and as a single data access point for everyone involved in the care of a patient? Medical record The medical record is a document and must meet guidelines for... Legal document Must meet guidelines for: Completeness What four things must every entry in a medical record include? Date Ethical practice dictates that nurses document only interventions that are __________________________ Preformed Can medical record entries be altered or obliterated? No What type of information is medical record documentation based on? Facts, not opinions What is the difference between EMR and EHR? EMR - Electronic Medical Record: is a record of one episode of care, such as an inpatient stay or an outpatient appointment EHR - Electronic health record: is a longitudinal record of health that includes the all information from one or more care settings Define Computerized Provider Order Entry (CPOE) Allows clinicians to enter orders in a computer that are sent directly to the appropriate department. May include medication interactions, screening and reminders for preventative health actions such as vaccinations The delivery of safe, evidence-based, high-quality nursing practice requires nursing documentation to be.. Clear What is PIE? Problem Intervention Evaluation Ex: What is APIE? Assessment Problem Intervention Evaluation Ex: What is SOAPIER? Subjective data Objective data Assessment Plan Interventions Evaluation Revision Ex: What is DAR? Data Action Response Ex: What is charting by exception (CBE)? Documentation that records only abnormal or significant data. Reduces charting time by assuming certain norms. **Each facility must define what is normal What is the goal of case management documentation? To achieve realistic and desired patient and family outcomes within appropriate lengths of stay and with appropriate use of resources What does the medication administration record (MAR) include? List of ordered medications Dosages Routes Times What is included in an admission summary? Patient history Medication reconciliation Initial assessment that address the patient's problems Identification of needs pertinent to discharge planning and formulation of a plan of care based on those needs What is included in the discharge summary? Addresses the patient's hospital course and plans for follow-up Documents the patient's status at discharge Includes information on: Discharge placement Patient education Follow-up appointments and referrals. What is seen as the most reliable source of information in any legal action lated to care? Medical record What is the right to privacy? The right to be free from intrusion or disturbance in a person's private life Right to control access to personal information When it comes to medical records, patients have the right to.. Obtain, view, update a copy of When do hand-offs occur? Between providers, between shifts, at the time of unit transfer or discharge referral Hand-off reporting should provide what type of information to the next caregiver? Why? Accurate, timely, and important information to ensure patient safety. What is a sentinel event? A safety occurrence that affects a patient and causes death, serious permanent or temporary injury, or requires interventions to sustain life. What is the S in SBAR? Situation What is happening at the current time? What is the B in SBAR? Background What are the circumstances leading up to this situation? What is the A in SBAR? Assessment What does the nurse think the problem is? What is the R in SBAR? Recommendation What should we do to correct the problem? A hospital has just implemented the use of electronic health records (EHRs). While learning to use this new system, the nurse realizes that EHRs may do which of the following? a. Limit access to the patient record to one person at a time b. Improve access to patient information at the point of care c. Negate the use of nursing documentation d. Increase the potential for medication errors b. Improve access to patient information at the point of care Rationale: Which statement best contributes to the nurse's documentation of assessment of patient status in the patient's medical chart? a. "Patient had a good day with minimal complaints. Patient was pleasant and cooperative during morning care." b. "Patient complained that the nurse didn't come quickly enough when she pressed the call button." c. "Patient rated pain 7/10 at 7:45 a.m. Received pain medication at 8 a.m. reporting pain 3/10 at 8:30 a.m." d. "Patient was grumpy today, even after administration of pain medication, a back massage, and a nap." c. "Patient rated pain 7/10 at 7:45 a.m. Received pain medication at 8 a.m. reporting pain 3/10 at 8:30 a.m." Rationale: A patient requests a copy of his medical record. What is the correct response by the nurse? a. Inform him that his record is the property of the facility and cannot be accessed by anyone but staff. b. Tell him that the Code for Nurses does not allow you to give him access to his records. c. Acknowledge that he has the right to have a copy of his records, and make arrangements per facility policy. d. Refer his request to the hospital administrator because all such requests need to go through proper channels. c. Acknowledge that he has the right to have a copy of his records, and make arrangements per facility policy. Rationale: A patient's sister comes to visit and asks to read the patient's medical records. What is the best response by the nurse? a. Settle her in a chair at the nurses' station and give her access. b. Respond that the contents of a patient's medical records are private and confidential. c. Tell her she can read the medical records only if the patient sits with her. d. Distract the sister by changing the subject and then walking away. b. Respond that the contents of a patient's medical records are private and confidential. Rationale: Which are reasons that accurate documentation in the medical record is important? Select all that apply. a. Reimbursement for care b. Evidence of care provided c. Communication between health care providers d. Nonlegal documentation of a nurse's actions e. Promotion of continuity of care a. Reimbursement for care b. Evidence of care provided c. Communication between health care providers e. Promotion of continuity of care Rationale: Which note is an example of the S in SBAR? a. Patient resting; pain was rated 3/10 1 hour after receiving narcotic analgesic. b. Patient was admitted on evening shift with a fractured right femur after a fall at home. c. Patient's pain was rated 8/10 before administration of narcotic pain medication. d. Assess pain every 2 hours, continue pain medication as prescribed, and provide backrub. a. Patient resting; pain was rated 3/10 1 hour after receiving narcotic analgesic. Rationale: Which attributes are important in nursing documentation? Select all that apply. a. Inconsequentiality b. Timeliness c. Relevancy d. Accuracy e. Factual basis b. Timeliness c. Relevancy d. Accuracy e. Factual basis Rationale: When should administered medications be documented? a. At the end of a shift when all medications have been given b. As given to avoid the possibility of double dosing c. After every meal to document at least three times daily d. When the nurse has time before going on break b. As given to avoid the possibility of double dosing Rationale: What is an advantage of the use of paper medical records? a. Charts with paper records are always available to all health care team members. b. Paper records do not need much storage space in the health care facility. c. Writing implements are always available on nursing units and patient rooms. d. Recording on paper does not require any special computer knowledge. d. Recording on paper does not require any special computer knowledge. Rationale: What is a purpose of a hand-off report? a. Ensures continuity of care and patient safety b. Keeps the doctor informed c. Completed when a patient is discharged to home d. Determines patient assignments a. Ensures continuity of care and patient safety Rationale: Which are primary functions of the medical record? Select all that apply a. Provides evidence of health care provider opinions b. Allows access to electronic patient records through the use of shared passwords c. Protects health care providers in legal matters d. Is a source of information for statistical data e. Provides a record of compliance with health care regulations c. Protects health care providers in legal matters d. Is a source of information for statistical data e. Provides a record of compliance with health care regulations A patient prescribed a semisolid diet consumes porridge and tolerates it well. How would the nurse document this finding? a. "The patient ate porridge and tolerated it well." b. "The patient ate porridge while reading a book." c. "The patient ate 6 oz of porridge without complaint." d. "The patient ate porridge, 6 oz and was w.t., w.a.p." c. "The patient ate 6 oz of porridge without complaint." Rationale: Which statement related to documentation done by unlicensed assistive personnel (UAP) is true? a. Documentation by UAP is not part of the medical record. b. UAP are not authorized to document patient activities of daily care. c. Registered nurses are responsible for reviewing documentation by UAP. d. A registered nurse may only do intake and output documentation. c. Registered nurses are responsible for reviewing documentation by UAP. A patient reports to the nurse, "I have a sharp and intense pain around the umbilicus." The patient rates the pain as 9 on a scale from 0 to 10. The nurse documents it as "The patient has abdominal pain and feels uncomfortable." Which characteristic of high-quality nursing documentation is lacking? a. Accuracy b. Timeliness c. Accessibility d. Retrievability a. Accuracy Rationale: Protected health information may be used for which purposes? a. Treatment b. Payment c. Creating a case study d. Health care operations e. Solicitation a. Treatment b. Payment d. Health care operations Which statements describe problem-oriented medical records and documentation? Select all that apply. a. Documentation usually follows a preset framework for organization. b. The medical record integrates charting from most or all health care professions in the same section. c. The medical record separates charting from medicine, nursing, physical therapy, nutrition, and other professions into various sections. d. Documentation is narrative. e. Documentation is strategically organized for easy reference by multiple professions. a. Documentation usually follows a preset framework for organization. b. The medical record integrates charting from most or all health care professions in the same section. e. Documentation is strategically organized for easy reference by multiple professions. In which way(s) does the decision support component of the electronic medical record assist health care providers? Select all that apply. a. Provides recommendations for treatment b. Allows ordering of a PET scan c. Describes past treatments d. Assists in the diagnostic process e. Provides reminders of preventive health actions such as vaccinations a. Provides recommendations for treatment d. Assists in the diagnostic process e. Provides reminders of preventive health actions such as vaccinations What is an incident report? Document, usually confidential, describing any accident or deviation from policies or orders involving a patient, employee, or visitor on the premises of a health care facility. Ex: Medication Error: a patient is given the incorrect dose of an analgesic Patient Fall: a child falls out of a hospital bed Equipment Malfunction: the cable of a powered bed sparks and starts to smoke Staff Injury: a patient knocks over an IV pole, which strikes a nurse on the head What is the main goal of the "Ticket-to-Ride" Communication Tool? Ensure appropriate patient care during transport and at the destination Which statements written in the nurse's record are accurate for a patient who has returned to the floor after a knee replacement? Select all that apply. a. Pain seems to be reduced. b. Percoset 2 tabs given for pain. c. IV restarted, infusing without difficulty. d. Heart rate: 75/min, Urine voided 300 mL, pain rated as 7 on a scale of 0-10. e. Temperature: 102 degrees Fahrenheit at 5 p.m., Paracetamol (Tylenol) 500 mg at 5 p.m., Temperature 99 degrees Fahrenheit at 6:30 p.m. d. Heart rate: 75/min, Urine voided 300 mL, pain rated as 7 on a scale of 0-10. e. Temperature: 102 degrees Fahrenheit at 5 p.m., Paracetamol (Tylenol) 500 mg at 5 p.m., Temperature 99 degrees Fahrenheit at 6:30 p.m. Rationale: Which characteristics are the benefits of electronic health records (EHRs) in a health care setting? Select all that apply. a. Reduced need for specialized training b. Reduction of medication errors c. Delivery of guideline-based care d. Information in narrative form e. Simultaneous access by multiple users b. Reduction of medication errors c. Delivery of guideline-based care e. Simultaneous access by multiple users Rationale: Which organization sets the standards for bedside clinical nursing documentation? a. North American Nursing Diagnosis Association b. American Nurses Association c. National League for Nursing d. U.S. House of Representatives b. American Nurses Association Rationale: Documentation is an important activity in nursing. Which organizational standards would be followed when doing documentation? a. American Nurses Association (ANA), 2010 b. The Joint Commission c. Diagnosis Related Groups d. Health Insurance Portability and Accountability Act (HIPAA) b. The Joint Commission Rationale: How is proper documentation of a patient's health information useful for the medical insurance companies? a. Provides preventive care to the patients b. Determines the diagnosis-related group (DRG) of the patient c. Reduces the cost of the monthly premium paid by the patient d. Reduces the cost of health care services provided to the patient b. Determines the diagnosis-related group (DRG) of the patient Rationale: A nurse is provided a form with preset standard findings for recording a progress note. The nurse reports the findings in the following way: " Physical Exam: All systems within normal limits except: left lower extremity, casted d/t to heel fracture. Review of Systems: All normal except pain in the left foot." This is referred to as which type of reporting? a. Narrative report b. Charting by exception c. PIE (Problem—Intervention—Evaluation) report d. DAR (Data, Action of Nursing Intervention, Response of the patient) report b. Charting by exception Rationale: A nurse manager is educating the nursing staff on the importance of security with the implementation of the electronic health record (EHR) system. Which points does the manager emphasize? Select all that apply. a. Do not share passwords with anyone. b. Do not log in to the patient's database. c. Do not log in with someone else's user access. d. Do not print information with personal health information (PHI). e. Do not leave the patient's medical record open on a computer screen. a. Do not share passwords with anyone. c. Do not log in with someone else's user access. e. Do not leave the patient's medical record open on a computer screen. Rationale: At the end of a shift, a nurse documents a patient's condition, anticipated condition, medications, and nursing interventions fulfilled, so that the next nurse can follow the appropriate treatment and care for the patient. Which kind of report is this? a. Incident b. Hand-off c. Telephone d. Discharge summary b. Hand-off Rationale: A nurse, after administering antibiotics, updates a patient's chart. Which elements of the report does the nurse accurately document to limit the nursing liability in case of a legal claim? Select all that apply. a. Drug allergies b. Discontinued medications c. Current medications given d. Name of drug manufacturer e. Size, shape, and color of the pills a. Drug allergies b. Discontinued medications c. Current medications given Rationale: A nurse spends a considerable amount of quality time documenting pertinent clinical patient data accurately and comprehensively. Which does effective documentation ensure? Select all that apply. a. Saving time of the physician and other members of the health care team b. Providing continuity of care c. Minimizing the risk of errors d. Protecting the nurse from legal issues e. Facilitating proper insurance reimbursement All of the above! Rationale: The nurse is preparing a discharge summary for the patient. Which information would the nurse provide in the discharge summary? Select all that apply. a. Entire biographical information of the patient b. Contact information of the health care provider c. Step-by-step instructions for self-administration of insulin d. Investigation procedures performed during the period of hospitalization e. Signs and symptoms that have to be reported to the health care provider b. Contact information of the health care provider c. Step-by-step instructions for self-administration of insulin e. Signs and symptoms that have to be reported to the health care provider Rationale: The nurse is passing the patient care to another nurse during change of shift. Which information would the nurse include in the hand-off report? Select all that apply. a. Nursing diagnosis of the patient b. Routine care procedures for the patient c. All biographical information of the patient d. Important information about family members e. Recent changes in objective measurements a. Nursing diagnosis of the patient d. Important information about family members e. Recent changes in objective measurements Rationale: The nurse caring for a patient in a home care setting needs a detailed documentation. Which descriptions are the purposes of the documentation? Select all that apply. a. Justifies reimbursement b. Provides data for acuity records c. Provides information regarding quality of work d. Provides the health care team with detailed knowledge for teamwork e. Serves as a reference document for other professionals involved in care a. Justifies reimbursement c. Provides information regarding quality of work d. Provides the health care team with detailed knowledge for teamwork e. Serves as a reference document for other professionals involved in care Rationale: You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which information do you include in the report? Select all that apply. a. The patient's name, age, and admitting diagnosis b. Allergies to food and medications c. Your evaluation that the patient is "needy" d. How much the patient ate for breakfast e. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol a. The patient's name, age, and admitting diagnosis b. Allergies to food and medications e. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol Rationale: Using the SOAP format, identify the appropriate "P" statement. a. Reposition the patient on right side. Encourage patient to use patient-controlled analgesia (PCA) device. b. The patient states, "The pain increases every time I try to turn on my left side." c. Acute pain is related to tissue injury from surgical incision. d. Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage. Pain noted on mild palpation. a. Reposition the patient on right side. Encourage patient to use patient-controlled analgesia (PCA) device. Rationale: The nurse has accidentally administered the wrong medication to a patient. Which nursing action is appropriate documentation? a. Not including the error because it is a commonly made mistake b. Including the error in the medical record c. Creating a hand-off report explaining the error and keeping it in the medical record d. Creating an incident report to help hospital management for quality improvement d. Creating an incident report to help hospital management for quality improvement Rationale: Which statements describe the advantages of documentation in nursing? Select all that apply. a. Documentation is essential for reimbursement. b. Documentation is an indicator of improved quality control. c. Documentation may provide protection from malpractice. d. Documentation entries may be added to or changed at any time. e. Documentation assists in identifying and justifying nursing interventions. a. Documentation is essential for reimbursement. c. Documentation may provide protection from malpractice. e. Documentation assists in identifying and justifying nursing interventions. Rationale: A primary health care provider calls the intensive care unit and orders 10 mg of morphine every 4 hours for a patient's pain. Which correct actions does a nurse take to record and follow the instructions? Select all that apply. a. The nurse adds the new medication to the current list of medications. b. The nurse administers 10 mg of morphine every 4 hours and documents it. c. The nurse records the details of the instructions and marks it as telephone order (TO). d. The nurse notes on the chart that medication was "administered as per orders." e. The nurse reads back the prescription to the primary health care provider for verification. b. The nurse administers 10 mg of morphine every 4 hours and documents it. c. The nurse records the details of the instructions and marks it as telephone order (TO). e. The nurse reads back the prescription to the primary health care provider for verification. Rationale: The nurse makes an incident report following a patient fall. The incident report helps serve which purpose? Select all that apply. a. Providing good quality health care b. Identifying the need to change a procedure or policy c. Reducing negative feedback of the patient related to health care delivered d. Determining the severity of the punishment to be delivered e. Identifying loopholes in the operation of the health care system a. Providing good quality health care b. Identifying the need to change a procedure or policy e. Identifying loopholes in the operation of the health care system Rationale: The nurse documents the following assessment findings of the patient with pneumonia. "Blood pressure is 150/90 mm Hg; pulse is 92 beats/min; respiratory rate is 22 breaths/min. The patient seems to have difficulty breathing. Sounds are produced when the patient exhales. Auscultation reveals rhonchi in the lower lung bases. Copious amounts of phlegm are produced since morning." Which statements in the documentation are considered to be poor quality reporting? Select all that apply. a. Sounds are produced when exhaling. b. The patient seems to have difficulty breathing. c. Auscultation reveals rhonchi in the lower lung bases. d. Copious amounts of sputum produced since morning. e. Vital signs: blood pressure - 150/90 mm Hg; pulse rate-92 beats/min; respirations- 22 breaths/min. a. Sounds are produced when exhaling. b. The patient seems to have difficulty breathing. d. Copious amounts of sputum produced since morning. Rationale: Which aspects of documentation might the nurse assign to unlicensed assistive personnel? Select all that apply. a. Vital signs b. Patient reports c. Laboratory data d. Medical history e. Activities of daily living a. Vital signs e. Activities of daily living Rationale: The nurse is discussing a case history. Which patient information would the nurse exclude from mentioning to maintain confidentiality of the patient? Select all that apply. a. Room number b. Medical history c. Demographic details d. Medical diagnoses e. Date of birth a. Room number c. Demographic details e. Date of birth Rationale: Which notes would the nurse include in the discharge summary forms when preparing a patient for discharge? Select all that apply. a. Dietary restrictions b. Follow-up care c. Emergency contact numbers d. Preoperative instructions e. Acuity records a. Dietary restrictions b. Follow-up care c. Emergency contact numbers Rationale: Which patient finding would the nurse report as subjective data?Information that is known only to the patient and family members is subjective data. Examples of subjective data include nausea, pain, anxiety, fear, depression, and discouragement. Option 3: Objective data are those things that the nurse can observe through the senses of hearing, sight, smell, and touch.
Which information that the nurse gives in report is objective?Objective data in nursing refers to information that can be measured through physical examination, observation, or diagnostic testing. Examples of objective data include, but are not limited to, physical findings or patient behaviors observed by the nurse, laboratory test results, and vital signs.
Which elements should a nurse find when reviewing a patient's electronic health record?Electronic Health Records: The Basics
Administrative and billing data. Patient demographics. Progress notes. Vital signs.
What should the nurse include when documenting?Documentation by nurses includes recording patient assessments, writing progress notes, and creating or addressing information included in nursing care plans. Nursing care plans are further discussed in the “Planning” section of the “Nursing Process” chapter.
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In which section of the patient health record would the nurse enter subjective and objective data quizlet?
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