Exam (elaborations)
PVN Ch. 5 Documentation (1)
PVN Ch. 5 Documentation (1)
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PVN Ch. 5 Documentationauditors - CORRECT ANSWER-People appointed to examine patient charts and health records to
assess quality of care
5 basic purposes of documentation - CORRECT ANSWER-Documented Communication
Permanent record for accountability
Legal record of care
Teaching
Research and Data collection
what is documentation important for (especially in home health) - CORRECT
ANSWER-Reimbursement
Documentation is an integral part of what phase of the nursing process - CORRECT
ANSWER-Implementation
Peer Review - CORRECT ANSWER-An in-house department study that may appraise the nursing
practice of individual nurses (audit each other)
Quality Insurance - CORRECT ANSWER-Audits in healthcare that evaluates services provided
and results, Evaluates care results against accepted standards, An in-house department study
Diagnosis-related groups (DRGs) - CORRECT ANSWER-A system that classifies patients by age,
diagnosis, and surgical procedure. Basis for reimbursement for medicare and medicaid.
Nurses Notes - CORRECT ANSWER-where nurses record observations, care given, and patient
responses
Institutions are reimbursed by insurance companies or government programs only for what? -
CORRECT ANSWER-Documented Care
If it wasn't documented - CORRECT ANSWER-it wasn't done
when you document the type of care, time of care, and your signature you are saying what? -
CORRECT ANSWER-interventions were implemented to meet the patients needs
Electronic Health Record - CORRECT ANSWER-increases efficiency, consistency & accuracy
eases of use and documentation
decreases cost
Point-of-Care - CORRECT ANSWER-Bedside System
How different departments/floors interact with each other
COWS - CORRECT ANSWER-Computers on Wheels
Security - CORRECT ANSWER-Follow your facilities policy and procedures
Always follow HIPAA
Always log off and Don't Share Passwords
, Personal Health Record - CORRECT ANSWER-Newer Concept, Comprehensive profile of the
patient, Patient can enter info as well
SBAR - CORRECT ANSWER-Situation
Background
Assessment
Recommendation
What is the SBAR used for - CORRECT ANSWER-Communicates between provider and nurse,
nurse & nurse
Additional R is added when done by telephone
Joint commission says it meets the national patient safety goals
Situation (SBAR) - CORRECT ANSWER-A concise statement of the problem
Background(SBAR) - CORRECT ANSWER-Pertinent and brief information related to the situation
Assessment(SBAR) - CORRECT ANSWER-Analysis and considerations of options - what you
found/think
Recommendation(SBAR) - CORRECT ANSWER-Action requested/recommended - what you want
Basic Guidelines for Documentation - CORRECT ANSWER-quality and accuracy
correct spelling, grammar, and punctuation
NO SPACES
sloppy handwriting is not acceptable
clear, concise, complete, and accurate
who is responsible for the initial admission nursing history, physical assessment, and development
of patient care? - CORRECT ANSWER-the RN
Charting Rules - CORRECT ANSWER-All sheets should have correct pt information, id number,
date, and time if applicable
USE ONLY APPROVED abbreviations and medical terms
be timely, specific, accurate, and complete
LEAVE NO SPACES
write legibly
Accurate Documentation is the best defense against what - CORRECT ANSWER-malpractice
How to correct an error - CORRECT ANSWER-mark one single line through error and above it
write error with your initials and circle it
How to sign your name - CORRECT ANSWER-SPNGCC
When should you chart? - CORRECT ANSWER-After care is given
HOw often should you chart? - CORRECT ANSWER-As soon and as often as possible
What do you chart when patient leaves unit? - CORRECT ANSWER-Time, method of
transportation on departure and return
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