Documentation EXAM 3 with correct answers | | | | |
The |act |of |recording |client |care |in |written |form |& |Creating |a |written |record |of |client |care. |- |
✔✔Documentation
documentation |of |client |care |is |a |__ |document |- |✔✔legal
What |information |to |include |in |the |chart? |- |✔✔Assessments
Medication |administration |and |response |to |medications
Treatments/Interventions |given |and |client |response
Client |education
The |Purpose |of |Documentation |- |✔✔Written |communication |between |providers/Decision |analysis
Permanent |record |continuity |of |care
Legal |documentation |of |care |"The |patient |who |never |dies"
Reimbursement
Educational |tool
Research |and |data |collection |and |Quality |Improvement
American |Nurses |Association |(ANA) |Standards |for |Documentation |- |✔✔Accurate |and |consistent
Clear, |concise, |and |complete, |reflecting |your |patient's |response |to |nursing |care
Timely |and |sequential
Organized |and |confidential |
Permanently |retrievable
Consistent |with |professional |standards |and |agency |standards
Able |to |withstand |scrutiny |during |an |audit
Basic |Documentation |Goals |- |✔✔Communicate |clearly, |using |specific, |objective |language
,Correct |patient |record |or |chart
Soon |as |the |patient |encounter |is |concluded
Give |exact |times |and |dates |for |assessments, |interventions, |and |other |events—Chronological |order
State |the |facts |in |a |straightforward |manner
Quote |the |patient |directly |when |appropriate
Describe |only |what |you've |seen, |heard, |smelled, |and |touched
Use |only |standard |abbreviations |and |correct |spelling
Documentation |Guidelines |- |✔✔Chart |in |black, |ballpoint |ink
Make |your |handwriting |neat |and |legible
Never |leave |spaces; |never |leave |blank
Changes |during |a |visit |or |from |previous |visits
What |you |observed
Telephone |calls |related |to |the |patient's |case |to |Dr. |and |other |personnel
Facts |only
Avoid |assumptions, |personal |onions |
Eliminate |bias
Avoid |assigning |'values' |
| (such |as |"normal")
Basic |Documentation |Goals |- |✔✔Never |alter |a |client's |record |(altering |a |client |chart |is |a |criminal |
offense) |
Never |correct |another |person's |entry
Do |not |sign |a |note |that |you |did |not |write
Always |reread |your |notes |for |accuracy
Include |consent |for |or |refusal |of |treatment, |client |responses |to |interventions, |calls |made |to |other |
health |care |professionals
Cross |through |the |error |once, |date, |time, |and |initial |the |change
| Do |not |recopy |any |charting |form
, | Do |not |make |photocopies |without |permission
Assessment |Specific |Documentation |Guidelines |- |✔✔Draw |pictures |when |appropriate
Use |anatomic |landmarks
Face |of |clock |to |describe |findings |that |are |in |a |circular |pattern
Do |not |insert |information |between |lines
If |an |error |is |made—use |a |single |line |to |cross |out |the |error, |then |date, |time |and |sign |the |correction |
(follow |agency |policy)
Don't |refer |to |documents |that |aren't |part |of |the |medical |record, |such |as |incident |reports
Include |your |signature |and |the |date
Remember |if |you |didn't |document |it, |it |wasn't |done
Documentation |Do's |and |don'ts:
Record |significant |events |or |changes |in |condition |- |✔✔do
Documentation |Do's |and |don'ts:
Any |attempts |you |have |made |to |contact |the |primary |care |provider |- |✔✔do
Documentation |Do's |and |don'ts:
Chart |false |information |- |✔✔don't
Documentation |Do's |and |don'ts:
Chart |teaching |performed |- |✔✔Do
Documentation |Do's |and |don'ts:
Chart |use |of |restraints, |including |reason |for |use, |type |of |restraints, |and |frequent |checks |of |the |client
|- |✔✔do
Documentation |Do's |and |don'ts:
The |act |of |recording |client |care |in |written |form |& |Creating |a |written |record |of |client |care. |- |
✔✔Documentation
documentation |of |client |care |is |a |__ |document |- |✔✔legal
What |information |to |include |in |the |chart? |- |✔✔Assessments
Medication |administration |and |response |to |medications
Treatments/Interventions |given |and |client |response
Client |education
The |Purpose |of |Documentation |- |✔✔Written |communication |between |providers/Decision |analysis
Permanent |record |continuity |of |care
Legal |documentation |of |care |"The |patient |who |never |dies"
Reimbursement
Educational |tool
Research |and |data |collection |and |Quality |Improvement
American |Nurses |Association |(ANA) |Standards |for |Documentation |- |✔✔Accurate |and |consistent
Clear, |concise, |and |complete, |reflecting |your |patient's |response |to |nursing |care
Timely |and |sequential
Organized |and |confidential |
Permanently |retrievable
Consistent |with |professional |standards |and |agency |standards
Able |to |withstand |scrutiny |during |an |audit
Basic |Documentation |Goals |- |✔✔Communicate |clearly, |using |specific, |objective |language
,Correct |patient |record |or |chart
Soon |as |the |patient |encounter |is |concluded
Give |exact |times |and |dates |for |assessments, |interventions, |and |other |events—Chronological |order
State |the |facts |in |a |straightforward |manner
Quote |the |patient |directly |when |appropriate
Describe |only |what |you've |seen, |heard, |smelled, |and |touched
Use |only |standard |abbreviations |and |correct |spelling
Documentation |Guidelines |- |✔✔Chart |in |black, |ballpoint |ink
Make |your |handwriting |neat |and |legible
Never |leave |spaces; |never |leave |blank
Changes |during |a |visit |or |from |previous |visits
What |you |observed
Telephone |calls |related |to |the |patient's |case |to |Dr. |and |other |personnel
Facts |only
Avoid |assumptions, |personal |onions |
Eliminate |bias
Avoid |assigning |'values' |
| (such |as |"normal")
Basic |Documentation |Goals |- |✔✔Never |alter |a |client's |record |(altering |a |client |chart |is |a |criminal |
offense) |
Never |correct |another |person's |entry
Do |not |sign |a |note |that |you |did |not |write
Always |reread |your |notes |for |accuracy
Include |consent |for |or |refusal |of |treatment, |client |responses |to |interventions, |calls |made |to |other |
health |care |professionals
Cross |through |the |error |once, |date, |time, |and |initial |the |change
| Do |not |recopy |any |charting |form
, | Do |not |make |photocopies |without |permission
Assessment |Specific |Documentation |Guidelines |- |✔✔Draw |pictures |when |appropriate
Use |anatomic |landmarks
Face |of |clock |to |describe |findings |that |are |in |a |circular |pattern
Do |not |insert |information |between |lines
If |an |error |is |made—use |a |single |line |to |cross |out |the |error, |then |date, |time |and |sign |the |correction |
(follow |agency |policy)
Don't |refer |to |documents |that |aren't |part |of |the |medical |record, |such |as |incident |reports
Include |your |signature |and |the |date
Remember |if |you |didn't |document |it, |it |wasn't |done
Documentation |Do's |and |don'ts:
Record |significant |events |or |changes |in |condition |- |✔✔do
Documentation |Do's |and |don'ts:
Any |attempts |you |have |made |to |contact |the |primary |care |provider |- |✔✔do
Documentation |Do's |and |don'ts:
Chart |false |information |- |✔✔don't
Documentation |Do's |and |don'ts:
Chart |teaching |performed |- |✔✔Do
Documentation |Do's |and |don'ts:
Chart |use |of |restraints, |including |reason |for |use, |type |of |restraints, |and |frequent |checks |of |the |client
|- |✔✔do
Documentation |Do's |and |don'ts:
