Fundamentals of Nursing Documentation Study Guide Review
Produces a written account of pertinent patient data, nurs-
Documentation: ing clinical decision and interventions, and patient re-
sponses in a health care record.
Means by which patient needs and progress, individual
Communication therapies, patient education, and discharge planning are
conveyed to others in the health care team.
Describes exactly what happens to the patient and must
Legal document
follow agency standards.
Classification system based on patients' medical diag-
Diagnostic-related groups (DRGs)
noses that support reimbursement.
Learning the nature of an illness and the individual pa-
Education
tient's responses.
Gathering of statistical data of clinical disorders, compli-
Research
cations, therapies, recovery, and deaths.
Objective, ongoing reviews to determine the degree to
Auditing
which quality improvement standards are met.
a. A positive impact on the quality of patient care through
interdisciplinary collaboration with improved data avail-
ability.
The purpose of the electronic health record is:
b. Improve patient safety through the use of clinical deci-
sion support.
a. Providers are required to notify patients of their pri-
vacy policy and make a reasonable ettort to get written
According to HIPAA (Health Insurance Portability and Ac-
acknowledgement of this notification.
countability Act), to eliminate barriers that could delay
care, providers are:
b. HIPAA requires that disclosure or requests regarding
health information are limited to the minimum necessary.
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, Fundamentals of Nursing Documentation Study Guide Review
The standards of documentation by The Joint Commission
The standards of documentation by the Joint Commission require documentation within the context of the nursing
require: process, as well as evidence of patient and family teaching
and discharge planning.
Five important guidelines must be followed to ensure A factual record contains descriptive, objective information
quality documentation and reporting. Explain: Factual about what a nurse sees, hears, feels, and smells.
An accurate record uses exact measurements, contains
Five important guidelines must be followed to ensure
concise data, contains only approved abbreviations, uses
quality documentation and reporting. Explain: Accurate
correct spelling, and identifies the date and caregiver.
Five important guidelines must be followed to ensure A complete record contains all appropriate and essential
quality documentation and reporting. Explain: Complete information.
Current records contain timely entries with immediate
Five important guidelines must be followed to ensure
documentation of information as it is collected from the
quality documentation and reporting. Explain: Current
patient.
Five important guidelines must be followed to ensure Organized records communicate information in a logical
quality documentation and reporting. Explain: Organized order.
Story-like format that has the tendency to have repetitious
Narrative
information and be time consuming.
Problem - oriented medical record (POMR) Database, problem list, care plan, and progress notes.
SOAP Subjective, objective, assessment, and plan.
SOAPIE SOAP with intervention and evaluation added.
Problem, intervention, and evaluation with a nursing ori-
PIE
gin.
Focus charting Use of DAR (data, action, and response.)
Progress notes One of several formats or structured notes within a POMR.
Focuses on deviations from the established norm or ab-
Charting by exception
normal findings; highlights trends and changes.
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Produces a written account of pertinent patient data, nurs-
Documentation: ing clinical decision and interventions, and patient re-
sponses in a health care record.
Means by which patient needs and progress, individual
Communication therapies, patient education, and discharge planning are
conveyed to others in the health care team.
Describes exactly what happens to the patient and must
Legal document
follow agency standards.
Classification system based on patients' medical diag-
Diagnostic-related groups (DRGs)
noses that support reimbursement.
Learning the nature of an illness and the individual pa-
Education
tient's responses.
Gathering of statistical data of clinical disorders, compli-
Research
cations, therapies, recovery, and deaths.
Objective, ongoing reviews to determine the degree to
Auditing
which quality improvement standards are met.
a. A positive impact on the quality of patient care through
interdisciplinary collaboration with improved data avail-
ability.
The purpose of the electronic health record is:
b. Improve patient safety through the use of clinical deci-
sion support.
a. Providers are required to notify patients of their pri-
vacy policy and make a reasonable ettort to get written
According to HIPAA (Health Insurance Portability and Ac-
acknowledgement of this notification.
countability Act), to eliminate barriers that could delay
care, providers are:
b. HIPAA requires that disclosure or requests regarding
health information are limited to the minimum necessary.
1/6
, Fundamentals of Nursing Documentation Study Guide Review
The standards of documentation by The Joint Commission
The standards of documentation by the Joint Commission require documentation within the context of the nursing
require: process, as well as evidence of patient and family teaching
and discharge planning.
Five important guidelines must be followed to ensure A factual record contains descriptive, objective information
quality documentation and reporting. Explain: Factual about what a nurse sees, hears, feels, and smells.
An accurate record uses exact measurements, contains
Five important guidelines must be followed to ensure
concise data, contains only approved abbreviations, uses
quality documentation and reporting. Explain: Accurate
correct spelling, and identifies the date and caregiver.
Five important guidelines must be followed to ensure A complete record contains all appropriate and essential
quality documentation and reporting. Explain: Complete information.
Current records contain timely entries with immediate
Five important guidelines must be followed to ensure
documentation of information as it is collected from the
quality documentation and reporting. Explain: Current
patient.
Five important guidelines must be followed to ensure Organized records communicate information in a logical
quality documentation and reporting. Explain: Organized order.
Story-like format that has the tendency to have repetitious
Narrative
information and be time consuming.
Problem - oriented medical record (POMR) Database, problem list, care plan, and progress notes.
SOAP Subjective, objective, assessment, and plan.
SOAPIE SOAP with intervention and evaluation added.
Problem, intervention, and evaluation with a nursing ori-
PIE
gin.
Focus charting Use of DAR (data, action, and response.)
Progress notes One of several formats or structured notes within a POMR.
Focuses on deviations from the established norm or ab-
Charting by exception
normal findings; highlights trends and changes.
2/6
