documentation Exam 2 with correct answers
| | | | |
Documentation |is |written |evidence |of: |- |✔✔Methods |of |Documentation
| Common |Chart |Forms
| Computerized |Documentation
| What |to |Chart
| Preventing |Potential |Legal |Problems |in |Documentation |-
| Common |Charting |Errors
| Common |Causes |of |Malpractice
What |are |the |purposes |of |legal |documentation? |- |✔✔A |patient's |medical |record |is |a |valuable |source |
of |data |for |all |members |of |the |health |care |team. |Data |entered |into |the |medical |record |facilitate |
interdisciplinary |communication; |provide |a |legal |record |of |care |provided; |justify |financial
|billing/reimbursement; |and |allow |for |auditing, |monitoring, |and |evaluation |of |care |provided. |Medical |
records |also |serve |as |sources |of |research |data |and |as |learning |resources |for |nursing |and |health |care |
education.
What |is |communication? |- |✔✔A |patient's |medical |record |is |one |way |that |members |of |the |health |care
|team |communicate |about |patients' |needs |and |responses |to |care, |clinical |decision |making, |individual |
therapies, |content |of |consultations, |patient |education, |and |discharge |planning. |The |record |is |the |most
|current |and |357accurate |continuous |source |of |information |about |a |patient's |health |care |status; |the |
plan |of |care |needs |to |be |clear |to |anyone |who |accesses |the |record |(see |Unit |3). |Information |
communicated |in |a |patient's |record |allows |health |care |providers |to |know |a |patient |thoroughly, |
facilitating |safe, |effective, |timely, |and |patient-centered |clinical |decision |making. |To |enhance |
communication |and |promote |safe |patient |care, |document |assessment |findings |and |patient |
,information |as |soon |as |possible |after |you |provide |care |(e.g., |immediately |after |providing |a |nursing |
intervention |or |completing |a |patient |assessment).
What |is |legal |documentation? |- |✔✔Accurate |documentation |is |one |of |the |best |defenses |for |legal |
claims |associated |with |nursing |care |(see |Chapter |23). |You |need |to |document |in |a |timely |manner. |
Documentation |needs |to |indicate |clearly |that |a |patient |received |individualized, |goal-directed |nursing |
care |on |the |basis |of |your |nursing |assessment. |When |documenting, |describe |exactly |what |happened |
to |a |patient |and |follow |agency |standards. |Documenting |the |nursing |process |is |a |critical |nursing |
responsibility |that |limits |nursing |liability |by |providing |evidence |that |you |maintained |nursing |practice |
standards |while |providing |patient |care
What |are |common |mistakes |in |documentation |that |lead |to |malpractice? |- |✔✔(1) |failing |to |record |
pertinent |health |or |drug |information, |(2) |failing |to |record |nursing |actions, |(3) |failing |to |record |
medication |administration, |(4) |failing |to |record |drug |reactions |or |changes |in |patients' |conditions, |(5) |
incomplete |or |illegible |records, |and |(6) |failing |to |document |discontinued |medications.
T/F: |Do |not |document |retaliatory |or |critical |comments |about |a |patient |or |care |provided |by |another |
health |care |professional. |Do |not |enter |personal |opinions. |- |✔✔true |
Rationale: |Statements |can |be |used |as |evidence |for |nonprofessional |behavior |or |poor |quality |of |care.
Correct |action: |Enter |only |objective |and |factual |observations |of |a |patient's |behavior |or |the |actions |of |
another |health |care |professional. |Quote |all |patient |statements.
T/F: |Correct |all |errors |promptly. |- |✔✔true |
rationale: |Errors |in |recording |can |lead |to |errors |in |treatment |or |may |imply |an |attempt |to |mislead |or |
hide |evidence.
correct |action: |Avoid |rushing |to |complete |documentation; |be |sure |that |information |is |accurate |and |
complete.
T/F: |Record |all |facts. |- |✔✔true |
Rationale: |Record |must |be |accurate, |factual, |and |objective.
, Correct |action: |Be |certain |that |each |entry |is |factual |and |thorough. |A |person |reading |your |
documentation |needs |to |be |able |to |determine |that |a |patient |received |adequate |care.
T/F: |Document |discussions |with |providers |that |you |initiate |to |seek |clarification |regarding |an |order |
that |is |questioned. |- |✔✔True |
rationale: |If |you |carry |out |an |order |that |is |written |incorrectly, |you |are |just |as |liable |for |prosecution |as
|the |health |care |provider.
correct |action: |Do |not |record |"physician |made |error." |Instead |document |that |"Dr. |Smith |was |called |to
|clarify |order |for |analgesic." |Include |the |date |and |time |of |the |phone |call, |with |whom |you |spoke, |and |
the |outcome.
T/F: |Document |only |for |yourself. |- |✔✔true |
rationale: |You |are |accountable |for |information |that |you |enter |into |a |patient's |record. |
correct |action: |Never |enter |documentation |for |someone |else |(exception: |if |caregiver |has |left |unit |for |
the |day |and |calls |with |information |that |needs |to |be |documented; |include |date |and |time |of |entry |and |
reference |specific |date |and |time |to |which |you |are |referring |and |name |of |source |of |information |in |
entry; |include |that |information |was |provided |via |telephone).
T/F: |Avoid |using |generalized, |empty |phrases |such |as |"status |unchanged" |or |"had |good |day." |- |
✔✔true
rationale: |This |type |of |documentation |is |subjective |and |does |not |reflect |patient |assessment.
correct |action: |Use |complete, |concise |descriptions |of |assessments |and |care |provided |so |
documentation |is |objective |and |factual.
T/F: |Begin |each |entry |with |date |and |time |and |end |with |your |signature |and |credentials. |- |✔✔true |
rationale: |Ensures |that |the |correct |sequence |of |events |is |recorded; |signature |documents |who |is |
accountable |for |care |delivered. |
correct |action:Do |not |wait |until |the |end |of |shift |to |record |important |changes |that |occurred |several |
hours |earlier; |sign |each |entry |according |to |agency |policy |(e.g., |M. |Marcus, |RN).
| | | | |
Documentation |is |written |evidence |of: |- |✔✔Methods |of |Documentation
| Common |Chart |Forms
| Computerized |Documentation
| What |to |Chart
| Preventing |Potential |Legal |Problems |in |Documentation |-
| Common |Charting |Errors
| Common |Causes |of |Malpractice
What |are |the |purposes |of |legal |documentation? |- |✔✔A |patient's |medical |record |is |a |valuable |source |
of |data |for |all |members |of |the |health |care |team. |Data |entered |into |the |medical |record |facilitate |
interdisciplinary |communication; |provide |a |legal |record |of |care |provided; |justify |financial
|billing/reimbursement; |and |allow |for |auditing, |monitoring, |and |evaluation |of |care |provided. |Medical |
records |also |serve |as |sources |of |research |data |and |as |learning |resources |for |nursing |and |health |care |
education.
What |is |communication? |- |✔✔A |patient's |medical |record |is |one |way |that |members |of |the |health |care
|team |communicate |about |patients' |needs |and |responses |to |care, |clinical |decision |making, |individual |
therapies, |content |of |consultations, |patient |education, |and |discharge |planning. |The |record |is |the |most
|current |and |357accurate |continuous |source |of |information |about |a |patient's |health |care |status; |the |
plan |of |care |needs |to |be |clear |to |anyone |who |accesses |the |record |(see |Unit |3). |Information |
communicated |in |a |patient's |record |allows |health |care |providers |to |know |a |patient |thoroughly, |
facilitating |safe, |effective, |timely, |and |patient-centered |clinical |decision |making. |To |enhance |
communication |and |promote |safe |patient |care, |document |assessment |findings |and |patient |
,information |as |soon |as |possible |after |you |provide |care |(e.g., |immediately |after |providing |a |nursing |
intervention |or |completing |a |patient |assessment).
What |is |legal |documentation? |- |✔✔Accurate |documentation |is |one |of |the |best |defenses |for |legal |
claims |associated |with |nursing |care |(see |Chapter |23). |You |need |to |document |in |a |timely |manner. |
Documentation |needs |to |indicate |clearly |that |a |patient |received |individualized, |goal-directed |nursing |
care |on |the |basis |of |your |nursing |assessment. |When |documenting, |describe |exactly |what |happened |
to |a |patient |and |follow |agency |standards. |Documenting |the |nursing |process |is |a |critical |nursing |
responsibility |that |limits |nursing |liability |by |providing |evidence |that |you |maintained |nursing |practice |
standards |while |providing |patient |care
What |are |common |mistakes |in |documentation |that |lead |to |malpractice? |- |✔✔(1) |failing |to |record |
pertinent |health |or |drug |information, |(2) |failing |to |record |nursing |actions, |(3) |failing |to |record |
medication |administration, |(4) |failing |to |record |drug |reactions |or |changes |in |patients' |conditions, |(5) |
incomplete |or |illegible |records, |and |(6) |failing |to |document |discontinued |medications.
T/F: |Do |not |document |retaliatory |or |critical |comments |about |a |patient |or |care |provided |by |another |
health |care |professional. |Do |not |enter |personal |opinions. |- |✔✔true |
Rationale: |Statements |can |be |used |as |evidence |for |nonprofessional |behavior |or |poor |quality |of |care.
Correct |action: |Enter |only |objective |and |factual |observations |of |a |patient's |behavior |or |the |actions |of |
another |health |care |professional. |Quote |all |patient |statements.
T/F: |Correct |all |errors |promptly. |- |✔✔true |
rationale: |Errors |in |recording |can |lead |to |errors |in |treatment |or |may |imply |an |attempt |to |mislead |or |
hide |evidence.
correct |action: |Avoid |rushing |to |complete |documentation; |be |sure |that |information |is |accurate |and |
complete.
T/F: |Record |all |facts. |- |✔✔true |
Rationale: |Record |must |be |accurate, |factual, |and |objective.
, Correct |action: |Be |certain |that |each |entry |is |factual |and |thorough. |A |person |reading |your |
documentation |needs |to |be |able |to |determine |that |a |patient |received |adequate |care.
T/F: |Document |discussions |with |providers |that |you |initiate |to |seek |clarification |regarding |an |order |
that |is |questioned. |- |✔✔True |
rationale: |If |you |carry |out |an |order |that |is |written |incorrectly, |you |are |just |as |liable |for |prosecution |as
|the |health |care |provider.
correct |action: |Do |not |record |"physician |made |error." |Instead |document |that |"Dr. |Smith |was |called |to
|clarify |order |for |analgesic." |Include |the |date |and |time |of |the |phone |call, |with |whom |you |spoke, |and |
the |outcome.
T/F: |Document |only |for |yourself. |- |✔✔true |
rationale: |You |are |accountable |for |information |that |you |enter |into |a |patient's |record. |
correct |action: |Never |enter |documentation |for |someone |else |(exception: |if |caregiver |has |left |unit |for |
the |day |and |calls |with |information |that |needs |to |be |documented; |include |date |and |time |of |entry |and |
reference |specific |date |and |time |to |which |you |are |referring |and |name |of |source |of |information |in |
entry; |include |that |information |was |provided |via |telephone).
T/F: |Avoid |using |generalized, |empty |phrases |such |as |"status |unchanged" |or |"had |good |day." |- |
✔✔true
rationale: |This |type |of |documentation |is |subjective |and |does |not |reflect |patient |assessment.
correct |action: |Use |complete, |concise |descriptions |of |assessments |and |care |provided |so |
documentation |is |objective |and |factual.
T/F: |Begin |each |entry |with |date |and |time |and |end |with |your |signature |and |credentials. |- |✔✔true |
rationale: |Ensures |that |the |correct |sequence |of |events |is |recorded; |signature |documents |who |is |
accountable |for |care |delivered. |
correct |action:Do |not |wait |until |the |end |of |shift |to |record |important |changes |that |occurred |several |
hours |earlier; |sign |each |entry |according |to |agency |policy |(e.g., |M. |Marcus, |RN).
