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Flashcards in Documentation Deck (24)
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1
Q

*EHR pros/cons?

A

advantage- improved access to info, info is private, faster to document, improved quality of care, enhanced communication and collaboration
disadvantage- expensive, downtime, difficult to onboard staff, lack of integration across different systems

2
Q

What is focus charting? What are the three sections? Pros/Cons?

A

Encourages you to view the patient’s status from a positive perspective rather than a problem oriented one. Three columns: time/date, focus/problem, DAR (data, action, response)
pros- addresses clients problems holistically
cons- no common problem list can lead to inconsistent labeling of the focus (problem)

3
Q

*Discharge planning starts when?

A

at admission

4
Q

What are the purposes of documentation? (8)

A
communication
continuity of care
QI
Planning and Evaluation
Legal Record
Professional Standards
Reimbursement
Education/Research
5
Q

What are the three reasons to use standardized language?

A

makes nursing visible
supports nursing research
better integration in EHR

6
Q

What is a source-oriented system? Pros/Cons?

A

different disciplines document in different sections

pros: easily locate care by a discipline
cons: data is scattered, especially treatments and outcomes

7
Q

What is a problem-oriented system? Pros/Cons?

A

organized according to client problems

pros: common problem list, promotes cooperation among team
cons: requires team cooperation and diligence

8
Q

What is narrative charting?

A

story of care chronologically.
pros- useful when constructing a timeline of events, like in emergency situations
cons- lack of standardization, slow to write, slow to read

9
Q

What is PIE charting? Whats one key component missing from it?

A

Problem, Interventions, Evaluation

Missing: planning phase

10
Q

What is SOAP(IER) charting?

A

S-ubjective- what client or family tells you (usually quoted)
O-bjective- factual/measurable clinical findings
A-ssessment- client problems or nursing diagnosis’
P-lan- STG and LTG
I-ntervention- actions performed
E-valuation- effectiveness of interventions
R-evision- changes made to original care plan

11
Q

What is FACT documentation? What four sections does it implement?

A
Charting that eliminates the need to chart normal findings.
F-flow sheets
A- assessment and baseline data
C- concise progress notes
T- timely entries
12
Q

What is included in a nursing admission data form?

A

cc, VS, allergies, meds, ADL status, physical assessment data, discharge planning

13
Q

What is included in a nursing discharge summary?

A

time of departure, transportation, name of persons accompanying pt, condition of patient, teaching provided, discharge instructions, followup appts

14
Q

What is a MAR? What does it include?

A

Medication Administration Record
chart meds- scheduled, unscheduled (ex: pre-op med), continuous, prn, stat, single-order
drug allergies
med refusal
assessment data required before administration
omitted or delayed administration
*electronic MAR may have med information such as interactions, indication, contraindications, safe dosage

15
Q

What is an IPOC? What does it map out? What are the advantages?

A

Integrated Plan of Care:
maps out day by day client goals, outcomes, interventions, treatments
pros- predicts length of stay, monitor costs of care, assists with staffing, eliminates duplicate charting, increases team effort, enhances nurses teaching

16
Q

What is an occurrence/incident report? How to write one?

A
formal record of an unusual event or accident that is NOT part of the clients record
Includes:
client, date, time, location
describe incident in objective terms
quote client or persons involved
identify witnesses
avoid drawing conclusions/placing blame
document actions taken and responses
17
Q

What is a MDS as it relates to long-term care?

A

Minimum Data Set- resident assessment and care screening must done within 14 days of admission and every 3 months thereafter

18
Q

How can a handoff report be given?

A

verbally, walking rounds (bedside), audio-recorded

19
Q

What is SBAR?

A

Situation- what is happening
Background- reason admitted, status, history, also vitals, meds, labs, code status
Assessment- what you believe the problem to be
Recommendation- what the patient needs

20
Q

What is a VO?

A

spoken order usually made during a client emergency

21
Q

What is a VORB or TORB?

A

verbal (telephone) order readback

22
Q

What are the 5 components of a POR?

A

Database, Problem list, Initial plan, Progress Notes, Discharge Planning

23
Q

What documentation is required for reimbursement of home healthcare?

A

monthly summary describing the client’s status and ongoing needs is required which the PCP signs (OASIS)

24
Q

What is a PACE handoff?

A

Patient/Problem
Assessment/Actions
Continuing/Changes
Evaluation