37 Multiple choice questions
- confidential, permanent legal documentation of information relevant to a client's health care.
- focuses on documenting deviations from the established norm or abnormal findings.
- oral, written or audiotaped exchanges of information between caregivers. (change of shift, telephone, transfer, incident)
- way to determine the hours of care and staff required for a give group of clients.
standards of health and the availability of health care, to foster high
standards for nursing, and to promote the professional development and
welfare of nurses.
reduces documentation time and highlights trends or changes.
disadvantage- system can pose legal risks if nurses do not document.
that allow nurses to quickly and easily enter assessment data about the
client. (ex. vital signs, hygeine, ambulation, meals, weight, etc.)
established guidelines that are used to care for clients with similar
health problems, that are based on the institution's standard of nursing
- legislation that protects client privacy for health information. (requires disclosure or requests regarding health information.)
- have become the basis for establishing reimbursement for client care.
- all together set nursing documentation standards.
- quality control and justification for reimbursement from Medicare, Medicaid or private insurance.
(state problem and chief complaints) 2)Background (admitting dx,
current meds, allergies, lab results, important info.) 3)Assessment
- instrumental in determining the standards and policies for documentation in long-term health care.
- arrangement for services by another care provider.
care plans that include client problems, key interventions, and
expected outcomes within an established time frame.
chart has a separate section for each discipline to record data. (ex.
nursing, medicine, social work, respiratory therapy)
system that provides basic summative information in the form of client
care summary that is printed for each client each shift for easy
method for recording that uses storylike format to document information
specific to client conditions and nursing care.
data 2)Objective data (measured and observed) 3)Assessment (diagnosis
based on data) 4)Plan (what caregiver plans to do)
- includes Medicare and Medicaid legislation for long-term documentation.
are grouped together by diagnosis, surgical procedures, complications,
preexisting conditions, age and everything done for a client must be
documented in the medical record so that the health care institution can
recover its costs.
- main purposes of records for patients.
- 1)Data (both subjective and objective) 2)Action of nursing intervention 3)Response of the client (evaluation of effectiveness)
-incorporates all aspects of nursing process, highlights client concerns and can be integrated in any clinical setting.
of documentation that emphasizes the client's problems. Data is
organized by problem or diagnosis. Includes: 1)Database 2)Problem list
3)Nursing care plan 4)Progress notes
- model of delivering care that incorporates a multidisciplinary approach to documenting client care.
- 1)Problem 2)Intervention 3)Evaluation
originates from nursing diagnosis, rather than medical diagnosis. Notes are numbered according to client's problems. Continuing problems documented daily.
- anything written or printed relating to the client, that you rely on as record or proof for authorized persons.
- professional caregiver providing formal advice to another caregiver.
- specify guidelines for documentation. (The Joint Commission)
- 1)Subjective data 2)Objective data 3)Assessment 4)Plan 5)Intervention 6)Evaluation
- 3 Formats for Progress Notes method
documentation within the context of the nursing process. requires that
accredited hospitals have written nursing policies and procedures and
quality improvement programs. requires multidisciplinary plan.
caregivers can easily locate each section to document entries.
disadvantage- client's problems are distributed across the record.
- nurses are legally and ethically obligated to keep information about clients confidential.
- best defense of legal claims associated with nursing care.
- unexpected outcomes, unmet goals, and interventions not specified within the critical pathway time frame.