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Documentation
The art of charting or making written notation of all the things that are pertinent to each pt for whom you provide care
one of the most important tasks you will perform on a daily basis
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Purposes of documentation
- 1. To communicate pertinent data to all health team members
- 2. To provide permanent record of medical diagnosis, nursing diagnosis
- 3. to serve as accountability for quality assurance, accreditation, and reimbursement
- 4. legal record for health care provider and pt
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Purpose of record of care
provides for future comparison of physical assessments, injuries and diagnostic tests
use for reference when pt seeks additional health care
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The Joint Commission
- Sets standards internationally and nationally for the quality of health care
- Audit medical records to verify facility compliance
- Seek to improve safety and quality of care for public
- Accredit facilities
- Have a set of reviewers who visit facility to assess its policy and procedures
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HIPPA
Health insurance portability and accountability act
pts right to review and obtain a copy of the medical record
Insures pts privacy rights
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Kardex
- Flip chart
- summary of care required by pt
- requires continual updating and maintenance
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When would you write an incident report?
- Med error
- pt injury, visitor injury, employee injury
- safety hazard
- damage equipment
- failure of appropriate health care
- failure to perform ordered care
- loss of pts belongings
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Guidelines for documentation
- blue or black ink
- write neatly
- sign each entry
- date and time - military
- follow chronological order
- chart in a timely manner
- be succinct
- use punctuations
- use appropriate abbreviations
- be accurate
- correct errors
- do not leave blank lines
- use continued notes
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When charting you should only chart subjective or objective data?
objective data
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Source Oriented Records
- Organized according to source or type of data
- use specific forms with each section designated by a labeled tab
- Disadvantage - time consuming
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Problem Oriented Records
organized around the pts individual problem
advantage - encourages collaboration between all health care workers
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Problem Oriented Record Sections
- 1. Data base
- 2. problem list
- 3. plan of care
- 4. progress notes
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Data to Document
- Physical and emotional assessment
- Nutrition
- hygiene
- activity level
- physician's visits
- elimination
- all nursing care interventions
- pts response to each intervention
- all pts complaints
- safety issues
- laboratory tests, X-rays, etc
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SOAPIER Charting
- S- Subjective data
- O- Objective Data
- A- Assessment
- P- Planning
- I- Interventions
- E- Evaluation
- R- Revisions
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PIE Charting
- P- Problem
- I- Intervention
- E- Evaluation
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Focus Charting
Focused on pts problems, concerns, and strengths
EX - DAR
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DAR Charting
- D- Data
- A- Action
- R- Response
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Charting by Exceptions
Charting only abnormal findings / nursing actions
- advantage - reduces time spent on charting
- disadvantage - absence of specific data in defense of your actions and pt conditions
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Narrative Charting
- Tells a story
- written in chronological ordering
- Written in paragraph form
- Advantage - detailed
- disadvantage - time consuming
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OBRA
- omnibus budget reconciliation act
- mandates the extensive assessment your MDS for resident essential and care screenings
- by 4 days of admission
- updated every 3 months
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Five Documentation Mistakes that Carry Increased Risks
- 1. Assessment findings
- 2. medications administered
- 3. pertinent health history
- 4. md orders
- 5. documenting on the wrong pt chart
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Ethnicity
the categorization of a group of people by a distinctive trait
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Culture
the way of life that distinguished a particular group of people from other groups
includes: beliefs, values, symbols, morals, laws, customs, religions, roles, art, music, attitude, races
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Culture Diversity
the differences between groups of people in a certain geographical area, such as city state or country
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Culture Competence
requires that the nurse makes a commitment to consider the cultural background of the pt and to provide appropriate care specific to the pt
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Cultural Awareness
knowledge of various cultures beliefs and values
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Cultural Sensitivity
Provide care to the pt and show respect for and incorporate the pts specific culture beliefs into your nursing care
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The nurse strives to understand anything that might influence the pts health including the pts:
- perceptions
- expectations
- behaviors
- decision-making processes
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Jewish
Consult with family regarding whether or not you may touch the body after death
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Latter-day Saints
- Sterilization is not permitted
- Abortion is prohibited
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Seventh Day Adventists
If anointment has taken place, avoid bath the pt for at least several hours
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Barriers to Health Care
- Economics
- Education
- Geography
- Language
- Stereotyping
- Prejudice and discrimination
- Misunderstanding
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Stereotyping
means that the person or group looks at another person or group through preconceived ideas or prefixed impressions
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Prejudice
Discrimination or judgement about a person or group based on irrational suspicion or hatred of a particular group, race, or religion
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Discrimmination
A type of unfair treatment of one or more persons or group
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Religion
formal structured system of beliefs, values, rituals, and practices of a person or group, based on the teachings of a God or spiritual leader
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Spiritualaity
explains the spirit and the relationship of the spirit to the body, mind, and environment
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Spiritual Care
Understanding of differences between spirituality, beliefs, and values
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Spiritual Distress
Nursing diagnosis related to spirituality
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What is (are) responsible for the population explosion in America leading to an increase in the diversity of the citizens?
Immigration
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What organization has worked to promote the pts right to culturally competent care in US hospitals?
Joint Commission
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Nursing care that involves or combines the elements of more than one culture is..?
Transcultural Care
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When the pt has expressed the feelings that God has caused his illness, what would the nurse consider when responding to his feelings?
NANDA Goals and Nursing interventions for spiritual distress
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A pt is bed written and is a member of the muslim religion, what would be the most appropriate to the pt to provide spiritual comfort
Turn pt bed towards MECCA 5 x a day for prayer
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Muslims male circumcision is for what purpose?
Cleansliness
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The nurse is assisting a Buddhist pt who is planning meals for the day, what would be appropriate for a low fat meal plan?
- steamed broccoli
- baked sweat potato
- spinach
- beans
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Which pt refuses blood transfusions due to religious beliefs?
Jehovah witness
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