Ch3 Documentation (1).pdf

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Upper Valley Educators Institute *

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1272

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Chemistry

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Feb 20, 2024

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Ch 3 Documenta�on Matching __D__1. CBE __I__2. DRGs __F__3. EHR __J__4. HIPAA __G__5. MDS __H__ 6. POC __B__ 7. DARE __C__ 8. SBARR __A__ 9. PIE __E__10. SOAPE a. Plan, interven�on, evalua�on b. Data, ac�on, response, educa�on c. Situa�on, background, assessment, recommenda�on, read back d. Char�ng by excep�on e. Subjec�ve, objec�ve, assessment, plan, evalua�on f. Electronic health record g. Minimum data sets h. Point of care i. Diagnosis - related groups j. Health Insurance Portability and Accountability Act Open Book Quiz 1) Name the five basic purposes for writen pa�ent records. • Documented communica�on, Permanent record for accountability, Legal record of care, Teaching, and Research and data collec�on. 2) What is a diagnosis - related group? • A System that classifies pa�ents by age, diagnosis, and surgical categories; used to predict the use of hospital resources including the length of stay.

3) List the four common issues in malprac�ce caused by inadequate documenta�on. • Not char�ng the correct �me that events occurred of that and event occurred at all, failing to record verbal orders, char�ng nursing care in advance, and documen�ng incorrect data. 4) Define narra�ve char�ng and describe what is included in its implementa�on. • Tradi�onal system of char�ng in which the nurse documents in story form all per�nent pa�ents, observa�ons, care and responses in the nurse notes sec�on of pa�ents records. 5) What does the acronym SOAPIER describe? • Format used in POMR. Components include Subjec�ve data (S) reported by the pa�ent, Objec�ve data (O) acquired by inspec�on, percussion, ausculta�on, and palpita�ons, and by test, usually measurable findings; Assessment (A) of the problem; Plan (P) of care; Interven�on (I); Evalua�on (E) of the pa�ent ’ s response to the treatment plan; Revisions (R) changes made. 6) How is the focus char�ng format used? • It is used by using the nursing process and more posi�ve concept of the pa�ent’s needs rather than medical diagnoses and problems. (DARE) Data, Ac�on, Response and evalua�on, Educa�on. 7) What are the procedures a nurse should follow when filling out an incident report? • 8) Describe acuity char�ng and explain why it is used. • It rates the pa�ent’s severity of illness and determines eﬃcient staﬃng paterns. 9) Who has ownership and access rights to health care records? • The original health record or chart is the property of the ins�tu�on or health care provider. 10) What are the major concerns regarding electronic documenta�on? • Confiden�ality, access to informa�on and inappropriate alterca�ons in pa�ent records are areas of concern. NCLEX REVIEW QUESTIONS 1. What is considered an appraisal by a professional co - worker of the manner in which an individual nurse conducts prac�ce, educa�on, or research? a. Peer review b. Assessment

c. Documenta�on d. Accountability 2. What form on the pa�ent’s chart do nurses record their observa�ons, care given, and the pa�ent’s responses? a. Health care provider’s orders b. Health record c. DRGs Nurses’ d. notes 3. The nurse is organizing the tasks and care that are required throughout the work shi�. What is the best �me to plan on documen�ng pa�ent care? a. During lunch b. As soon as possible a�er comple�on of care c. At the end of the shi� d. Only when necessary 4. During which phase of the nursing process does documenta�on take place? a. Planning b. Evalua�on c. Implementa�on d. Assessment 5. Considering the pa�ent’s medical record is a legal document, what is the most important considera�on the nurse should make? a. Document only what the pa�ent says. b. Clearly indicate goal - directed nursing care. c. Write as litle as possible so as not to incriminate yourself. d. Provide informa�on on only the abnormal ac�vi�es that occur. 6. As a newly hired nurse, what is the best way to chart using correct abbrevia�ons? a. Ask the other nurses on the unit to verify the used abbrevia�ons. b. Don’t worry about abbrevia�ons; they are not that important. c. Chart using the abbrevia�ons learned in school. d. Check to see if the facility has a published list of abbrevia�ons. 7. When char�ng by excep�on, which acronym is generally used? a. SOAPE b. SOAPIER c. PIE d. DARE 8. A pa�ent has been admited to the medical ﬂoor. Whose responsibility is it to complete the pa�ent’s ini�al admission nursing history, physical assessment, and development of the care plan? a. Social worker

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b. Health care provider c. LPN d. RN 9. Computer char�ng is becoming an increasingly common way to document. How o�en should the password be changed? a. Every 6 months b. Every 4 days c. With current technology, it is not necessary to change passwords d. At the discre�on of the ins�tu�on 10. The nurse is preparing to document pa�ent care. What data is most important for the nurse to include? (Select all that apply.) a. Temperature of the environment b. Type of procedure performed c. Family members present d. Pa�ent’s pain level e. Ti me of care Short Answer 1. The nurse does not have �me to document a procedure a�er it was completed Discuss how the nurse would handle a “late entry.” • When the nurses has �me the can go back to the pa�ents chart and add the entry with (LE) late entry document what needs to be stated and make sure she put an arrow where the entry should be. 2. Compare and contrast focused char�ng, char�ng by excep�on, and narra�ve char�ng. • Focused char�ng was developed by nurses using the nursing process and use t he DARE format. Char�ng by excep�on has the nurses doing all the ini�al assessments in the beginning of the shi� and only adding addi�onal treatment throughout the day. Narra�ve Char�ng is from computerized and noncomputerized char�ng which the nurses record their observa�ons, care given, and pa�ent response. 3. Brieﬂy iden�fy how long - term and home health care documenta�on are different from acute care (hospital) documenta�on. • The nature of the home health se�ng dictates that a narrower scope of people witness the majority of care, and in long term care the pa�ent live in the facility. And are referred to as residents.