Ch 16, 19 questions with correct answers rated A+

Ch 16, 19Identify the purposes of the client record - Communication among health professionals, Education of health professionals, Legal documentation detailing the client's care, Quality assurance, Identification of the cost of care, Health research What are the key differences between source-oriented and problem-oriented records? - The source-oriented record is organized according to discipline. Each discipline charts in its defined section of the chart. The problem-oriented record is organized around a patient problem list. All disciplines chart on shared notes that are referenced to the identified problem. Summarize the characteristics of narrative - tells the story of the patient's experience in a chronological format. Patient status, activities, and response to treatment may all be included in narrative charting. Summarize the characteristics of SOAP - is organized according to subjective data, objective data, assessment, and plan. This format may be used to address single problems or to write summative patient notes. Summarize the characteristics of PIE - is organized according to problem, interventions, and evaluation. Problems are identified at the admission assessment. Subsequent entries begin with identification of the problem number. This type of charting establishes an ongoing care plan. Summarize the characteristics of Focus® - is not necessarily organized according to problems. It can highlight the client's concerns, problems, or strengths. Charting occurs in three columns. The first column contains the time and date. The second column identifies the focus or problem addressed in the note. The third column contains charting in a DAR format. DAR is an acronym for data, action, and response. Summarize the characteristics of CBE - utilizes pre-printed flowsheets to document most aspects of care. CBE assumes that unless a separate entry is made—an exception—all standards have been met with a normal response. CBE flowsheets vary by specialty and in some cases even by diagnosis. Charting by exception simplifies nursing documentation by eliminating the need to document routine, stable patient information. It should be used in conjunction with flowsheets and brief narrative charting to ensure comprehensive documentation. This form of documentation does not minimize risks because nurses need to be sure they have included both routine and variant findings. It can be used successfully in any type of healthcare setting. Liability does not increase if the nurse follows reasonable and prudent guidelines for documenting patient care information. Identify at least five types of charting forms. - There are many types of charting forms. Among them are admission nursing databases, flowsheets, graphic records, intake and output records (I&O), medication administration records (MAR), nursing assessment flowsheets, progress notes, discharge summaries, and computerized charting. Occurrence forms - are not part of the patient record and as such are not charting forms, to document unusual events (occurrence forms), An occurrence report is a formal record of an unusual occurrence or accident. This is an agency report and is not part of the patient's chart. An occurrence report is filed in many circumstances. Examples of reportable events include falls or other patient injury, loss of patient belongings, or administration of the wrong medicine. Occurrence forms are used to track problems and identify areas for quality improvement. the Kardex - are not part of the patient record and as such are not charting forms, to summarize care What should you document after administering a PRN medication - After administering a PRN medication, document the time and date the medication was given and the location of administration if the medication was injected on the medication administration record (MAR)., In the nurses' notes, state the reason for administering the medicine, the amount given, and the patient's response to the medication pc - after meals Home care documentation - must include (1) certification of homebound status, (2) ongoing assessment of the need for skilled care, (3) use of the OASIS data set, and (4) a monthly summary describing the patient's status and ongoing needs. The patient's physician signs this form, and this is submitted for reimbursement. Long-term care documentation - must include (1) a comprehensive assessment using the Minimum Data Set for Resident Assessment and Care Screening (MDS) within 4 days of admission and updates every 3 months with any significant change in client condition, (2) a report of any changes in a client's condition to the primary care provider and the client's family, and (3) a summary by an LVN/LPN or RN either weekly for clients receiving skilled services or every 2 weeks for clients receiving intermediate care services