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What is documentation?
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Terms in this set (68)
the act of recording patient assessments and (nursing) care in written or electronic form

care of a patient in chronological order provided by all healthcare providers, the patient's response to interventions and treatments, important facts about a patient's health history, past and present illnesses, examinations, diagnostic tests, treatments, and patient's outcomes

the basic guideline used for nursing documentation is the nursing process
use of information technology provides more accurate documentation, direct access to diagnostic results, and direct access to medication profiles because the nurse has access to patient information in real time!

Confidentiality is also protected when the nurse documents at the bedside using a secure log-in and password.
Nursing documentation is an important part of effective communication among nurses and with other healthcare providers. As such, the nurse:
A. document facts.
B. document whenever its convenient.
C. document in a "block" fashion once per shift.
D. document how one feels about the care being provided.
oAfter performing a nursing admission history & physical examination.
oA change in patient's condition or health status.
oAfter performing a nursing procedure.
oAfter receiving and assessing a post-operative patient.
oAfter receiving and assessing an ICU transfer patient.
oWhen addressing a nursing diagnosis, a patient concern, or a (new) problem.
Common Formats for Nurses' Notes (read pages 444-450)Narrative format: chronological order of patient's experience. PIE = Problem, Intervention, Evaluation. SOAP(IER) = Subjective, Objective, Assessment, Plan (Intervention, Evaluation, Revision). Focus charting / DAR(P) = Data, Action, Response, Plan. FACT / Charting by exception (CBE): records only abnormal or significant data. Flow sheets [i.e. VS, nursing assessments, and I&Os]. Assessment features with baseline parameters. Concise, integrated progress notes & flow sheets [documents patient's condition and responses]. Timely entries documented when care is given. Electronic entry: Electronic health records (EHRs) change documentation formats from paper to electronic.Which statement is most important for the new graduate nurse to follow regarding documentation? A. Document the client's feelings. B. Only document a sudden change in a client's health status. C. Use abbreviations approved by the healthcare facility. D. Use the narrative format of charting even if it is not the institution's charting method.CP.I.E. ChartingP: problem statement: patient reports pain 7/10 on surgical incision I: Intervention: Given morphine 1mg IV at 23:35 E: Evaluation: patient reports pain as 1/10 at 23:55Nursing documentation is based on: A. the nursing process. B. the state boards of nursing. C. the nurse's personal preference. D. the National League for Nurses (NLN).AWhat Forms do Nurses use to Document Nursing Care?❑Nursing admission data forms. ❑Discharge (DC) summary. ❑Flow sheets and graphic records. ❑Medication administration records (MARs). ❑Kardex® (or Patient Care Summary). ❑Integrated Plan of Care (IPOC). ❑Incident / Occurrence reports.The client has fallen when trying to climb out of bed. The nurse: A. should omit this fall from the medical record. B. needs to complete an incident report as a risk management document. C. must document that an incident report was completed in the medical record. D. Completes an incident report since it is a permanent part of the medical record.BWhat is a handoff report?(sometimes called a change-of-shift report or handover report): to alert the next caregiver about the patient's status; SBAR report or IPASS report. It includes basic identifying information about each patient: Patient's name. Medical diagnosis & allergies. Code status. Precautions (if any). Bed designation. Room number. Attending/consulting physicians. Other important data/information: Abnormal occurrences during your shift. Any unfilled orders that need to be continued onto the next shift. Current appraisal of each patient's health status. Current orders (especially any newly changed orders). Patient/family concerns, needs, and questions. Reports on transfers/discharges.What is a SBAR hand off report? (slide 26 nurs informatics)(I = Identity/Introduction.) S = Situation. B = Background. A = Assessment. R = Recommendation. (R = Read back of orders/response.) *RN-to-MD SBAR report (for a patient's critical condition) differs from the RN-to-RN SBAR hand-off (or change-of-shift) report!What is a IPASS hand off report? (slide 27 nurs informatics)I = Illness severity. P = Patient summary. A = Action list. S = Situation awareness & contingency planning. S = Synthesis by receiver.Nursing informatics (slide 28)specialty that integrates nursing science, computer science, and information science to manage and communicate data, wisdom, information, and knowledge in nursing practiceHow do informatics enhance the nursing profession?oFacilitates a literature search: identifies the information, formulates a precise definition of a problem, and conducts a search of the most recent literature and most relevant studies oProvides literature databases: which are catalogs of articles usually sorted by discipline such as nursing and medicine- exist for engineering, education, law, medicine, nursing and other disciplines oProvides online sources for and of nursing research: for scholarly articles and general interest or popular interest periodicals oReduces barriers to evidence-based practice (EBP): computers at the workplace help to overcome this barrier to evidence based practice by providing fast easy access to current practice information from around the worldWhich activity by a nurse demonstrates information literacy? A. Organizing client data to study trends. B. Researching an unfamiliar medical diagnosis online. C. Learning a new electronic health record (EHR) system. D. Using social media to contact a former client to go on a date.BHow do nurses use informatics work? (slide 32 informatics)oComputers. oElectronic communication: ❑E-mail. ❑Group distribution lists. ❑Internet. ❑Social networking. ❑Telehealth.Which organization audits charts regularly? A. The Joint Commission. B. Hospital administration. C. The state boards of nursing. D. American Nurse Association (ANA).AComputer/application based tools for care (read 1637-1640)oAs a nurse, you will use a wide variety of computerized devices in the workplace: Track patients and equipment. Manage staffing and workflow. Reduce errors with automation. Aid patients with self-care. Perform / document patient care and clinical tasks. Manage time and tasks.What would be the best option for an elderly client who does not want to leave the house during the pandemic to see the primary care provider (PCP)? A. Telehealth. B. Go to urgent care. C. Call 911 (emergency services) for transportation. D. Talk to the PCP over the telephone for medical advice.AWhat is electronic medical record? (EMR)a record of one episode of care [i.e. an inpatient stay or an outpatient appointment]. The primary purpose of the medical record is communication! Current episode of patientWhat is electronic health record? (EHR)longitudinal record of health that includes the information from inpatient and outpatient episodes of healthcare from one or more care settings. Major components EHRs: Health information. Diagnostic test results. Order-entry system. Decision support. The use of EHRs improves patient health status! The nursing process (assessment, diagnosis, planning, implementation, and evaluation) is integrated in the EHR through documentation related to each of the five steps.What is the computerized provider order entry? (CPOE)The use of computerized provider order entry (CPOE) enables orders to go directly to the appropriate department decreasing the potential for errors!At the start of a hospital shift, the oncoming nurse grabbed a mobile computer but noticed that the outgoing nurse did not log off the electronic health record (EHR). What should the nurse do next? A. Find another mobile computer. B. Document in the EHR under the outgoing nurse. C. Report the outgoing nurse to the nurse manager. D. Log off the outgoing nurse from the EHR before using it.DThe nurse has just admitted a patient with chest pain (CP). When completing the admission paperwork, the nurse needs to record: A. health insurance status. B. an interpretation of patient behavior. C. objective data that are observed. D. subjective data that are observed.CWhat is the primary purpose of the medical record? A. Research. B. Communication. C. Professional standards. D.Quality improvement (QI).BThe integration of computers, information science, and nursing for the communication and management of data, information, & wisdom is: documentation. health literacy. medical informatics. nursing informatics.DThe use of electronic health records (EHRs): A. decreases storage space. B. improves client health status. C. requires basic computer skills. D. has not been shown to reduce medication errors.BWhich of the following does the nurse recognize as data in an electronic health record? A client's personal opinions. A client's full set of vital signs (VS). The nurse's interpretation of a client's change in condition. The doctor's admission history & physical examination (H&P).BWhich method of documentation is unique in that it does not develop a separate plan of care but instead incorporates the plan of care into the progress notes? A. Focus charting. B. Source-oriented records. C. Problem-oriented records. D. PIE (problem, intervention, evaluation).DWhich of the following are RN duties regarding telephone orders (T.O.)? Select all that apply. A. Sign the orders with name and title. B. Date and note the time orders were issued. C. Record the orders in patient's medical record. D. Read orders back to practitioner to verify accuracy. E. Record telephone orders, and full name and title of physician or nurse practitioner who issued orders.ABCDEWhich of the following are potential breaches in patient confidentiality? Select all that apply. A. Displaying information on a public screen. B. Sharing printers among units with differing functions. C. Discarding copies of patient information in trash cans. D. Faxing confidential information to unauthorized persons. E. Sending confidential e-mail messages via public networks. F. Sending minimal confidential information in an encrypted email. G. The healthcare team discussing a patient in a conference room with the door closed.ABCDEThe patient accuses the nurse of negligence after a fall when ambulating for the first time since hip replacement surgery. Which action is the best defense against this allegation? A. Keep an accurate medical record. B. Document patient data on the flow sheet. C. Notify the nursing supervisor of the patient condition. D. Accurately document patient care on the patient record.DThe nurse has a two-way video communication with the specialist involved in the care of a patient in a long-term care (LTC) facility. What example of nursing informatics technology was involved? A.Social media. B.Electronic health record (EHR). C.Patient engagement technology. D.Mobile technology & telemedicine.DThe nurse takes a patient's vital signs (VS). Where would the nurse document the VS? A.Flow sheets. B.Progress notes. C.Electronic medical record (EMR). D.Electronic medication administration record (E-MAR).AWhat are the 3 layers of the skin?epidermis, dermis, subcutaneous tissuewhat is the epidermis?The epidermis is the outer portion of the skin. The epidermis is made up of four or five layers, of which the most important are the inner and outer layers. The stratum corneum, the outermost layer, is composed of numerous thicknesses of dead cells. Functioning as a barrier, it restricts water loss and prevents fluids, pathogens, and chemicals from entering the body. The stratum germinativum, the innermost layer of the epidermis, continually produces new cells, pushing the older cells toward the skin surface. In the dermal layer, the keratinocytes are protein-containing cells that give the skin strength and elasticity. Deeper in the epidermis are melanocytes, which produce melanin, a pigment that gives skin its color and provides protection from ultraviolet light. Langerhans cells are mobile. Their function is to phagocytize (engulf) foreign material and trigger an immune response.What is the dermis?The dermis lies below the epidermis and above the subcutaneous tissue. It is made of irregular fibrous connective tissue that provides strength and elasticity to the skin and is generously supplied with blood vessels. Within the dermis are sweat glands, sebaceous (oil) glands, ceruminous (wax) glands, hair and nail follicles, sensory receptors, elastin, and collagen.What is the subcutaneous layer?The subcutaneous layer is composed primarily of connective and adipose tissue. It provides insulation, protection, and a reserve of calories in the event of severe malnutrition. This layer varies in thickness in different body sites. Sex hormones, genetics, age, and nutrition also influence the distribution of subcutaneous tissue.What are the functions of the skin?Absorption: applying lotion, topical meds Body temperature regulation. Elimination: waste Immunologic. Protection. Psychosocial: anxiety, depression Sensation: nerves Vitamin D production: sun exposure for bone health/calcium absorption and also affects immune responseNursing assessment of skin, hair, and nailsoHealth history (subjective data): ❑Demographic data: where they live, ex: more sun exposure in some areas compared to others ❑Socioeconomic status: any barriers to obtaining skin protected items, ex: sunscreen ❑PMH/PSH (i.e. acne, eczema). ❑Medication list and allergies (drug, environmental, and/or food). maybe can cause erythema ❑Family and genetic risk ❑Nutrition status: how much fluid, what type of fluid, what foods are you eating ❑Current health problems.Nursing assessment of skin, hair, and nails (con't)oNursing exam (objective data): ❑Skin inspection & palpation: ➢Color, edema, lesions, integrity, moisture level and Skin turgor. ➢Lesions (primary & secondary) and its distribution. Put on gloves before assessing a client who has open lesions! ➢Assess each skin lesion for: A - Asymmetry of shape. B - Border irregularity. C - Color variation within one lesion. D - Diameter >6mm. E - Evolving/changing featuresWhat are factors affecting skin integrity?Age: Older adult skin: Less elastic, drier, reduced collagen, areas of hyperpigmentation, more prone to injury Mobility status: Increased pressure, shearing, and friction can lead to breakdown> shearing is a combination of friction and gravity ex: semi fowler's position for long period, while friction is rubbing skin against an object Nutrition/hydration Protein: Maintain the skin, repair minor defects, and preserve intravascular volume Vitamin C, zinc, copper (formation of collagen) Dehydration = poor turgor Sensation level Diminished sensation leads to increased risk for pressure and breakdown. Impaired circulation: Negatively affects tissue metabolism Medications: Side effects: itching, rashes Moisture: Leads to maceration, ex: incontinence, incontinence and fever are the most common sources of moisture Fever: Depletes moisture Increases metabolic rate Infection: Impedes healing Lifestyle: Tanning, bathing, piercings, tattoosOf the following factors, which would put a client at greatest risk for impaired skin integrity? ▪ A. Medication B. Moisture C. Decreased sensation D. DehydrationCWhat is an intentional wound?Done on purpose, ex: surgical incisionWhat is an unintentional wound?a wound that was not planned/ obtained by injury accidents (rashes, pressure ulcers, etc)Open wounds vs closed woundsopen: any break in the skin integrity, ex: incision, stab, laceration, exposed to environmental factors, potential injury, and infection; more likely to heal at slower pace closed: tissues are injured but the skin is not broken, ex: fractures, bruisesacute vs chronic woundsacute: wounds that heal as expected and has a short duration, ex: burns chronic: underlying condition, any conditions that affect circulatory system/intravascular system, delay in healing ex: pressure injury, ulcerswhat is a wounda break or disruption in the normal integrity of the skin and tissuesWhat are the phases of wound healing?1. In hemostasis, involved blood vessels constrict and blood clotting begins. 2. In the inflammatory phase, white blood cells move to the wound. ex: swelling, pain, temapature elevation, migration of WBC 3. In the proliferation phase, granulation tissue is formed to fill the wound. ex: (1-21 days)rebuilding of tissue 4. In the maturation phase, collagen is remodeled, forming a scar. scar tissue forms, begins in the 2nd or 3rd week and can take over 3-6 months homeostasis and inflammatory phase happen at the same time andWhat is the Braden scale and the score meanings?Braden scale: Sensory perception, moisture, activity, mobility, nutrition, and friction or shear Total score less than 18 = risk, any number higher not at riskWhat are some nursing diagnoses for alterations in skin?Risk for Impaired Skin Integrity Impaired Skin Integrity Risk for Impaired Tissue IntegritySpecial considerations for pressure injuriesNurses play a major role in prevention and treatment. Pressure injury affects 15% of hospitalized clients. Pressure injuries are caused by unrelieved pressure to an area, resulting in ischemia.What is an intrinsic factor relating to pressure injury development and some examples?intrinsic factors are naturally occurring within the body ex: Immobility Impaired sensation Malnourishment Aging FeverWhat is an extrinsic factor relating to pressure injury development and some examples?mechanical factors such as pressure, friction, shearing, exposure to moistureWhat is stage I of pressure injuryDefined area of intact skin with non-blanchable redness(erythema) of a localized area, usually over a bony prominence.What is stage II of pressure injury?Involves a partial thickness loss of dermis and usually presents as a shallow, open ulcer. may also present as intact or open serum filled blisterWhat is stage III of pressure injury?full-thickness skin loss; not involving underlying fascia.What is stage IV of pressure injury?Involve full thickness tissue loss with exposed bone and tendon or muscleWhat is a Deep Tissue Injury?An area of skin that is intact but persistently discolored. It might be purplish or deep red, painful, or boggy, or have a blisterWhat is unstageable pressure injury?Involves full-thickness skin loss. The base of the wound is obscured by slough (tan, yellow, gray, green, or brown necrotic tissue) or eschar (tan, black, or brown leathery necroticWhat are some nursing interventions for pressure injuries?Prevention Meticulous skin care and moisture control Adequate nutrition Frequent repositioning Therapeutic mattresses Client/family teaching