Basic Nursing Thinking Doing And Caring - CH. 18
Documenting & Reporting Exam Study Guide
Explain the purposes of documentation. - answer Documentation is the act of recording
patient status and care. Documentation is used to create and record client assessments
and care, create a record of the client's health history, document care in chronological
order, and record the client's responses to interventions and treatments.
Compare and contrast electronic and written documentation. - answer The EHR
consists of records that are entered via computer. EHR's typically combine
source-oriented and problem-oriented record styles, but the source-oriented system is
most common. Advantages of using EHR: enhanced communication and collaboration,
improved access to information, time saving, improved quality of care, and information
is private and safe. Disadvantages of EHR: expense, downtime, difficulties associated
with change, and lack of integration. Written documentation is not common anymore,
but some healthcare facilities still use paper health records. Advantages of paper health
records: care providers are comfortable with it because it is familiar, there is no
downtime for system changes, and it is inexpensive. DIsadvantages of paper health
records: access is delayed (because only one care provider can access the record at a
time), documentation is time consuming, high risk for patient care error, and
confidentiality is difficult to protect.
What is source-oriented charting? - answer Usually used for patients in hospitals and
long term care facilities and includes the following sections: admission data, advance
directive, history and physical, providers orders, progress notes, laboratory data,
graphic data, rehabilitation and therapy notes, and discharge planning.
What are problem-oriented records? (POR's) - answer Organized around the patient's
problems and consists of four parts: The databases, the problem list, the plan of care,
and progress notes.
What is charting by exception? (CBE) - answer A system of charting in which only
significant findings or exceptions to standards and norms of care are documented.
What are some common types of charting? - answer Narrative: Records the story of
client's experience in chronological format. May be lengthy.
Electronic entry: Streamlined electronic process. Makes documentation more accurate
and efficient.
Identify 6 approved abbreviations that can be used for documenting in clinical
environments. - answer - ADL's: activities of daily living.
- Ad lib: as desired, if the patient desires.
Documenting & Reporting Exam Study Guide
Explain the purposes of documentation. - answer Documentation is the act of recording
patient status and care. Documentation is used to create and record client assessments
and care, create a record of the client's health history, document care in chronological
order, and record the client's responses to interventions and treatments.
Compare and contrast electronic and written documentation. - answer The EHR
consists of records that are entered via computer. EHR's typically combine
source-oriented and problem-oriented record styles, but the source-oriented system is
most common. Advantages of using EHR: enhanced communication and collaboration,
improved access to information, time saving, improved quality of care, and information
is private and safe. Disadvantages of EHR: expense, downtime, difficulties associated
with change, and lack of integration. Written documentation is not common anymore,
but some healthcare facilities still use paper health records. Advantages of paper health
records: care providers are comfortable with it because it is familiar, there is no
downtime for system changes, and it is inexpensive. DIsadvantages of paper health
records: access is delayed (because only one care provider can access the record at a
time), documentation is time consuming, high risk for patient care error, and
confidentiality is difficult to protect.
What is source-oriented charting? - answer Usually used for patients in hospitals and
long term care facilities and includes the following sections: admission data, advance
directive, history and physical, providers orders, progress notes, laboratory data,
graphic data, rehabilitation and therapy notes, and discharge planning.
What are problem-oriented records? (POR's) - answer Organized around the patient's
problems and consists of four parts: The databases, the problem list, the plan of care,
and progress notes.
What is charting by exception? (CBE) - answer A system of charting in which only
significant findings or exceptions to standards and norms of care are documented.
What are some common types of charting? - answer Narrative: Records the story of
client's experience in chronological format. May be lengthy.
Electronic entry: Streamlined electronic process. Makes documentation more accurate
and efficient.
Identify 6 approved abbreviations that can be used for documenting in clinical
environments. - answer - ADL's: activities of daily living.
- Ad lib: as desired, if the patient desires.
