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Study sets matching "nursing documentation"

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Study sets matching "nursing documentation"

43 terms
Nursing Documentation
Documentation
Standards for documentation
Documentation must be...
Confidential
anything written or printed relating to the patient--fundamen…
all patients must have an assessment of physical, psychosocia…
within context of nursing process
nurses are legally and ethically obligated to keep all pt inf…
Documentation
anything written or printed relating to the patient--fundamen…
Standards for documentation
all patients must have an assessment of physical, psychosocia…
35 terms
Nursing documentation
Documentation
Standards
Confidentiality
Potential breeches in confidentiality
Anything written or printed relating to the patient. ... It refl…
Institutional standards/policies often dictate frequency of d…
Nurses are legally and ethically obligated to keep all pt inf…
Displaying info on a public screen... Sharing printers among uni…
Documentation
Anything written or printed relating to the patient. ... It refl…
Standards
Institutional standards/policies often dictate frequency of d…
11 terms
Nursing Documentation
Legal requirements
Ethical requirements
Moral Requirements
Implications for nursing care
can be used in court. must be good enough to go in front of a…
should be honest and true. no subjective information and shou…
? duh don't be a liar
if you didn't document it it didn't happen
Legal requirements
can be used in court. must be good enough to go in front of a…
Ethical requirements
should be honest and true. no subjective information and shou…
19 terms
Nursing Documentation
What is documentation
Documentation provides proof of?
Why must you document ... 1. tracks ____…
Confidentiality in Documentation... only…
Legal record of client care ... legally, without documentation…
proof of Care
1. quality ... 2. continuity... 3.legally... 4.trends... 5. professional…
HIPPA rule 2003 law... providers must give client written info…
What is documentation
Legal record of client care ... legally, without documentation…
Documentation provides proof of?
proof of Care
45 terms
Nursing Documentation
Why is proper nursing documentation im…
Define Documentation
What is the purpose of creating patien…
Define how proper documentation should…
Because it creates a legal record of all patient interactions…
The written or typed legal record of all pertinent interactio…
1. Communication (between disciplines, ie doctors, other nurs…
The content in the record should be complete, accurate, conci…
Why is proper nursing documentation im…
Because it creates a legal record of all patient interactions…
Define Documentation
The written or typed legal record of all pertinent interactio…
Nursing - Documentation
Documentation
abd
BP
c/o
Written or typed legal record
Abbreviation for abdomen
Abbreviation for blood pressure
Abbreviation for complains of
Documentation
Written or typed legal record
abd
Abbreviation for abdomen
44 terms
Documentation - Nursing
Five basic purposes for accurate and c…
5 areas that should be covered in docu…
DRG's
What are DRG's
1. Written Communication... 2. Permanent record for accountabili…
1. Physical... 2. emotional... 3. psychosocial... 4. social... 5. spiritual
Diagnosis-related groups.
System that classifies patients by age, diagnosis and surgica…
Five basic purposes for accurate and c…
1. Written Communication... 2. Permanent record for accountabili…
5 areas that should be covered in docu…
1. Physical... 2. emotional... 3. psychosocial... 4. social... 5. spiritual
51 terms
Nursing Documentation
Documentation - Statutory and regulato…
Nursing unprofessional conduct
Competency to practice nursing
All cases are
"Legible medical records, produced by hand or electronically,…
"Any conduct or practice that is or might be harmful or dange…
For purposes of ARS 32-1601(24)(d), a practice that is or mig…
closed cases or cases in which the statute has run
Documentation - Statutory and regulato…
"Legible medical records, produced by hand or electronically,…
Nursing unprofessional conduct
"Any conduct or practice that is or might be harmful or dange…
36 terms
Nursing documentation
Documentation
Standards
Confidentiality
Potential breeches in confidentiality
Anything written or printed relating to the patient. ... It refl…
Institutional standards/policies often dictate frequency of d…
Nurses are legally and ethically obligated to keep all pt inf…
Displaying info on a public screen... Sharing printers among uni…
Documentation
Anything written or printed relating to the patient. ... It refl…
Standards
Institutional standards/policies often dictate frequency of d…
11 terms
nursing documentation
nursing unprofessional conduct
practices that are harmful or dangerou…
case files
the patient record need to be
- any conduct or practice that is or might be harmful or dang…
- failing to maintain a patient record that accurately reflec…
- all case files are closed cases or cases in which the statu…
- documentation should be factual and objective, not judgment…
nursing unprofessional conduct
- any conduct or practice that is or might be harmful or dang…
practices that are harmful or dangerou…
- failing to maintain a patient record that accurately reflec…
32 terms
Nursing Documentation
Documenation
Patient record
What role does JCAHO play in documenti…
What is the best defense of negligence…
Written or typed legal record of all pertinent patient intera…
Compilation of a patients health information, nursing respons…
Specified that assessment , diagnoses/patient needs , interve…
Permanent legal record of interactions
Documenation
Written or typed legal record of all pertinent patient intera…
Patient record
Compilation of a patients health information, nursing respons…
107 terms
Documentation-Nursing
Purpose of Medical record... Communication
Reimbursement
Education
Research
Important way for health team members to communicate about a…
(DRG's) Diagnostic Related Groups provide a codeable diagnosi…
Effective way for student to learn nature of illness and pati…
Statistical data relating to freq. of disorders, complication…
Purpose of Medical record... Communication
Important way for health team members to communicate about a…
Reimbursement
(DRG's) Diagnostic Related Groups provide a codeable diagnosi…
22 terms
Nursing Documentation
Nursing Responsibilities
Purposes of Health Documentation
Source Oriented
Interdisciplinary Record
You are what you write: grammar, spelling, legibility, etc.... C…
1. Communication w/ other care providers... 2. Written finding u…
Type of documentation... Each health care discipline keeps data…
Type of documentation... Combination of all health care discipli…
Nursing Responsibilities
You are what you write: grammar, spelling, legibility, etc.... C…
Purposes of Health Documentation
1. Communication w/ other care providers... 2. Written finding u…
16 terms
Nursing documentation
Purpose of records
Communication
Auditing
Research
- Communication... - Planning patient care... - Auditing... - Research
The record is a means by which healthcare team members commun…
A regular review of information in client records provides a…
Statistical data relating to the frequency of clinical disord…
Purpose of records
- Communication... - Planning patient care... - Auditing... - Research
Communication
The record is a means by which healthcare team members commun…
15 terms
Nursing documentation
documentation
principles of documentation
Where to chart
Documentation forms
anything written or electronically generated that describes t…
Factual... Accurate... Complete... Current (timely)... Organized... Complian…
Paper-based documentation... Electronic health records
Flowsheets... Progress notes... Discharge and referral summaries
documentation
anything written or electronically generated that describes t…
principles of documentation
Factual... Accurate... Complete... Current (timely)... Organized... Complian…
10 terms
Nursing Documentation
Purposes of records
DRG
Recording Don'ts
Guidelines for Quality Documentation
- communication... - reimbursement... - legal documentation... - educa…
Diagnosis Related Group... = system for reimbursement for health…
- erase, correction liquid, scratch out error... - document reta…
Factual... Accurate... Complete... Current... Organized
Purposes of records
- communication... - reimbursement... - legal documentation... - educa…
DRG
Diagnosis Related Group... = system for reimbursement for health…
14 terms
Nursing documentation
Types of documentation
Care plan
Kardex
narrative
care plan, kardex, narrative, flowsheets, MAR
set up from assesment through evaluation
Usually computer, vital signs, basic info
describe what happened to a patient when
Types of documentation
care plan, kardex, narrative, flowsheets, MAR
Care plan
set up from assesment through evaluation
12 terms
Nursing Documentation
Nursing Documentation
Effective communication
Source-oriented
Problem-oriented medical record
charting, recording or documenting onto a client's chart or c…
Main purpose of nursing documentation?
Easy for healthcare team members to locate different sections…
Encourages collaboration among healthcare team and care is or…
Nursing Documentation
charting, recording or documenting onto a client's chart or c…
Effective communication
Main purpose of nursing documentation?
14 terms
nursing documentation
health insurance portability and accou…
subjective
objective
ABC
to set privacy standards... patients have right to change inaccu…
"client states"
physical assessment findings... coldspa... changes in patients cond…
accurate... brief... complete
health insurance portability and accou…
to set privacy standards... patients have right to change inaccu…
subjective
"client states"
18 terms
Nursing Documentation
Why do we document
Documentation
Types of documentation
What to document
-Written record of nursing interactions... -Guide for reimbursem…
-Written nursing or interdisciplinary care plans are the fram…
-Care plan... -Nursing kardex/ patient care summary ... -Progress,…
-Admission, transfer, discharge... -New or changed information/…
Why do we document
-Written record of nursing interactions... -Guide for reimbursem…
Documentation
-Written nursing or interdisciplinary care plans are the fram…
19 terms
Nursing Documentation
What is documentation
Documentation provides proof of?
Why must you document ... 1. tracks ____…
Confidentiality in Documentation... only…
Legal record of client care ... legally, without documentation…
proof of Care
1. quality ... 2. continuity... 3.legally... 4.trends... 5. professional…
HIPPA rule 2003 law... providers must give client written info…
What is documentation
Legal record of client care ... legally, without documentation…
Documentation provides proof of?
proof of Care
14 terms
Nursing Documentation
R E A S O N S F O R D O C U M E N T A…
R E A S O N S F O R D O C U M E N T A…
R E A S O N S F O R D O C U M E N T A…
T O O L S F O R D O C U M E N T A T I…
Through documentation, nurses communicate to other nurses and…
Documentation encourages nurses to assess client progress and…
Documentation is a valuable method for demonstrating that, wi…
Nurses use worksheets to organize the care they provide, and…
R E A S O N S F O R D O C U M E N T A…
Through documentation, nurses communicate to other nurses and…
R E A S O N S F O R D O C U M E N T A…
Documentation encourages nurses to assess client progress and…
37 terms
Documentation in Nursing
Documentation
Documentation Guidelines
When documenting, record _____ of beha…
What terms should be avoided when docu…
The written, legal record of all pertinent interactions with…
consistent with professional and agency standards... complete, a…
observations
subjective terms: good, normal, average, sufficient
Documentation
The written, legal record of all pertinent interactions with…
Documentation Guidelines
consistent with professional and agency standards... complete, a…
175 terms
Documentation , History, and Nursing Process
Issues of bioethics
Quality of Life
Futile Care
Allocating scarces resources
1. Quality of Life... 2. Futile care ... 3. Allocating scarces Reso…
Central to discussions about futile care, cancer therapy , ph…
Unlikely to produce benefit
Key issue in assess of care
Issues of bioethics
1. Quality of Life... 2. Futile care ... 3. Allocating scarces Reso…
Quality of Life
Central to discussions about futile care, cancer therapy , ph…
27 terms
Documentation- Nursing 371
A nurse who fails to log off a compute…
A patient has the right to obtain, rev…
Documentation is:
The steps of Nursing Process
True
False. They can review or obtain but cannot revise their heal…
Written or electronic legal record of all pertinent interacti…
Assessing, Diagnosing, Planning, Implementing, and evaluating
A nurse who fails to log off a compute…
True
A patient has the right to obtain, rev…
False. They can review or obtain but cannot revise their heal…
8 terms
Nursing 100 - Documentation
Documentation
Effective Documentation
HIPAA
Examples of Breaches in HIPAA
A legal and permanent, written or electronic record of all pe…
Must include: Content, Time, Date, Format, Accountability, an…
Health Insurance Portability and Accountability Act
Displaying of information on a computer screen, Computers lef…
Documentation
A legal and permanent, written or electronic record of all pe…
Effective Documentation
Must include: Content, Time, Date, Format, Accountability, an…
40 terms
Documentation of Nursing Care
medical record (chart)
documentation
The Joint Commission
Medicare/insurance companies
a legal record that contains all orders, tests, treatments, a…
provides a written record of the history, treatment, care, an…
sets standards for documentation
rely on documentation to determine actual length of stay, pro…
medical record (chart)
a legal record that contains all orders, tests, treatments, a…
documentation
provides a written record of the history, treatment, care, an…
27 terms
Nursing Documentation Assessment
Axill/o
Or/o
Neur/o
Ophthalm/o
Armpit
Mouth
Nerve
Eye
Axill/o
Armpit
Or/o
Mouth
70 terms
Nursing Process, Documentation Abbreviations
a (with line over)
abd
a.c.
ad lib
before
abdomen
before meals
as desired
a (with line over)
before
abd
abdomen
51 terms
nursing documentation (NCI)
Why do we document?
Why do we document?
Why do we document?
Why do we document?
provides written record of history treatment care response of…
Serve as evidence in court of law (legal record of care- may…
Teaching purpose (how to document appropriately) research and…
Used in licensing and accreditation... Justifies reimbursment... De…
Why do we document?
provides written record of history treatment care response of…
Why do we document?
Serve as evidence in court of law (legal record of care- may…
27 terms
Fundementals of Nursing: Documentation
What are the purposes of documentation?
What is JCAHO and what do they do?
Objective
Subjective
Planning client care, Communication, Legal Documentation, Res…
Joint Commission on Accreditation of Healthcare Organizations…
Draw an unopinionated picture with your words
Use quotes. Ex: "I feel dizzy when I sit up"
What are the purposes of documentation?
Planning client care, Communication, Legal Documentation, Res…
What is JCAHO and what do they do?
Joint Commission on Accreditation of Healthcare Organizations…
19 terms
Exam 1 Nursing Documentation
What is documentation
Documentation provides proof of?
Why must you document ... 1. tracks ____…
Confidentiality in Documentation... only…
Legal record of client care ... legally, without documentation…
proof of Care
1. quality ... 2. continuity... 3.legally... 4.trends... 5. professional…
HIPPA rule 2003 law... providers must give client written info…
What is documentation
Legal record of client care ... legally, without documentation…
Documentation provides proof of?
proof of Care
28 terms
Nursing Documentation and SBAR Communication
What are the Primary purpose of nursin…
Documentation must be these 6 things
Concise documentation means that that…
this is an example of a ___ nurse note
Provide evidence that practice standards have been upheld... Co…
Timely... Legible... Concise... Accurate... Complete... Logically organized
Brief... Incomplete sentences... Eliminate words that do not chan…
Experienced dyspnea ambulating in hall. Returned to bed via W…
What are the Primary purpose of nursin…
Provide evidence that practice standards have been upheld... Co…
Documentation must be these 6 things
Timely... Legible... Concise... Accurate... Complete... Logically organized
12 terms
Nursing Lecture- Documentation
why is documented needed?
model used to provide a structured not…
4 elements of documenting
identifies content or purpose of the n…
communication, legal documentation, education, research
focused charting
focus, data, action, evaluation
focus column
why is documented needed?
communication, legal documentation, education, research
model used to provide a structured not…
focused charting
Documentation and Reporting in Nursing Practice
Purpose of Patient Records
HIPAA
All documentation must be:
Guidelines for documentation
Communication... Diagnostic and Therapeutic orders... Care planning…
Health Insurance Portability Accountability Act... -pt has right…
Accurate... Bias free... Complete... Detailed... Easy to read... Factual... Gra…
-use commonly accepted abbreviations... -correctly sign entries…
Purpose of Patient Records
Communication... Diagnostic and Therapeutic orders... Care planning…
HIPAA
Health Insurance Portability Accountability Act... -pt has right…
26 terms
Chapter 7 - (Nursing) Documentation
What is a Chart ?
What does Charting, Recording or Docum…
What does Good documentation reflect?
What are the Five purposes for accurat…
Also called a health record, they are Legal Records used to m…
Involve interventions carried out to meet the patient's needs…
Reflects nursing process
1) Written Communication... 2) Permanent Record for Accountabili…
What is a Chart ?
Also called a health record, they are Legal Records used to m…
What does Charting, Recording or Docum…
Involve interventions carried out to meet the patient's needs…
51 terms
documentation & nursing process
a legal record that is used to meet ma…
process of adding information to the c…
recording the interventions carried ou…
electronic pt record designed for heal…
Chart (health care record)
Charting Record
Documenting
Electronic Medical Record (EMR)
a legal record that is used to meet ma…
Chart (health care record)
process of adding information to the c…
Charting Record
78 terms
Nursing 110 Documentation
Discussion
Effective documntation
Report
When to report?
-Informal oral communication
-accessible... -accurate... -relevant... -consistent... -audible... -clear... -…
-Oral, paper, or computer based... -Face-to face... -Tape Recorded…
-Change in shift... -Leaving the unit... -Transferring a patient... -R…
Discussion
-Informal oral communication
Effective documntation
-accessible... -accurate... -relevant... -consistent... -audible... -clear... -…
16 terms
Nursing Exam 2 Documentation
goals of documentation
purposes of documentation
MAR
CPOE
relevant to goals/ patient response
communication ... assessments... plan care... educate QA and research
medication ... administration... record
computerized ... provider ... order ... entry
goals of documentation
relevant to goals/ patient response
purposes of documentation
communication ... assessments... plan care... educate QA and research
17 terms
Nursing funds 12 documentation
Medical record
Traditional medical record
Medication administration record
Flow sheets ... Narrative charting ... EMR
chart,patient care record
Hard plastic chart with tabbed dividers
MAR stands for
Types of charting
Medical record
chart,patient care record
Traditional medical record
Hard plastic chart with tabbed dividers
70 terms
Nursing Abbreviations of Documentation
a
ac
ADL
AD
Before
Before Meals
Activities of Daily Living
Right Ear
a
Before
ac
Before Meals
97 terms
Nursing Documentation Abbreviations
a (with line over)
Abd
Ad lib
AM
Before
Abdomen
As desired
Morning
a (with line over)
Before
Abd
Abdomen
191 terms
Abbreviations for Nursing Documentation
ā
abd
ac
ADLs
before
abdomen
before meals
activities of daily living
ā
before
abd
abdomen
78 terms
Nursing Documentation & Informatics
informatics
data
information
informatics used throughout healthcare
Managing and processing of information necessary to make deci…
raw, unprocessed numbers, symbols, or words, subjective and o…
data that have been interpreted
temperature readings, ID badges/numbers,
informatics
Managing and processing of information necessary to make deci…
data
raw, unprocessed numbers, symbols, or words, subjective and o…
26 terms
Chapter 7 - (Nursing) Documentation
What is a Chart ?
What does Charting, Recording or Docum…
What does Good documentation reflect?
What are the Five purposes for accurat…
Also called a health record, they are Legal Records used to m…
Involve interventions carried out to meet the patient's needs…
Reflects nursing process
1) Written Communication... 2) Permanent Record for Accountabili…
What is a Chart ?
Also called a health record, they are Legal Records used to m…
What does Charting, Recording or Docum…
Involve interventions carried out to meet the patient's needs…
40 terms
Nursing 110 Documentation Basics
Documentation
Patient Record
Source-oriented record
Advantage of source-oriented record
Written or typed legal record of all pertinent interactions w…
Compilation of patient's health information
one in which each healthcare group keeps data on its own sepa…
Each discipline can easily find and chart pertinent data
Documentation
Written or typed legal record of all pertinent interactions w…
Patient Record
Compilation of patient's health information
59 terms
Nursing Process/Documentation/Informatics
Process
Nursing Process
Assessment
Comprehensive Assessment
A series of steps or acts that lead to accomplishing some goa…
A systematic method for providing care to clients. Purpose is…
The first step in the nursing process. Includes systematic co…
Completed upon admission. Provides baseline client data inclu…
Process
A series of steps or acts that lead to accomplishing some goa…
Nursing Process
A systematic method for providing care to clients. Purpose is…
8 terms
Nursing Data Collection and Documentation
Differentiate between a nursing assess…
the four basic types of assessment
Initial Comprehensive Assessment
Ongoing or partial assessment
Nursing assessment - Collective subjective and objective data…
Initial Comprehensive Assessment... Ongoing or partial assessmen…
Includes: a. Subjective data concerning client's perception o…
Includes: Data collection after comprehensive data base estab…
Differentiate between a nursing assess…
Nursing assessment - Collective subjective and objective data…
the four basic types of assessment
Initial Comprehensive Assessment... Ongoing or partial assessmen…
26 terms
Chapter 7 - (Nursing) Documentation
What is a Chart ?
What does Charting, Recording or Docum…
What does Good documentation reflect?
What are the Five purposes for accurat…
Also called a health record, they are Legal Records used to m…
Involve interventions carried out to meet the patient's needs…
Reflects nursing process
1) Written Communication... 2) Permanent Record for Accountabil…
What is a Chart ?
Also called a health record, they are Legal Records used to m…
What does Charting, Recording or Docum…
Involve interventions carried out to meet the patient's needs…
43 terms
Fundamentals of Nursing: Documentation
Documentation:
Communication
Legal document
Diagnostic-related groups (DRGs)
Produces a written account of pertinent patient data, nursing…
Means by which patient needs and progress, individual therapi…
Describes exactly what happens to the patient and must follow…
Classification system based on patients' medical diagnoses th…
Documentation:
Produces a written account of pertinent patient data, nursing…
Communication
Means by which patient needs and progress, individual therapi…
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