Intro Ch 5 & 8

  1. 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
  2. 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
  3. 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
  4. 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
  5. HIPPA
    Health insurance portability and accountability act

    pts right to review and obtain a copy of the medical record

    Insures pts privacy rights
  6. Kardex
    • Flip chart
    • summary of care required by pt
    • requires continual updating and maintenance
  7. 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
  8. 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
  9. When charting you should only chart subjective or objective data?
    objective data
  10. 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
  11. Problem Oriented Records
    organized around the pts individual problem

    advantage - encourages collaboration between all health care workers
  12. Problem Oriented Record Sections
    • 1. Data base
    • 2. problem list
    • 3. plan of care
    • 4. progress notes
  13. 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
  14. SOAPIER Charting
    • S- Subjective data
    • O- Objective Data
    • A- Assessment
    • P- Planning
    • I- Interventions
    • E- Evaluation
    • R- Revisions
  15. PIE Charting
    • P- Problem
    • I- Intervention
    • E- Evaluation
  16. Focus Charting
    Focused on pts problems, concerns, and strengths

    EX - DAR
  17. DAR Charting
    • D- Data
    • A- Action
    • R- Response
  18. 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
  19. Narrative Charting
    • Tells a story
    • written in chronological ordering
    • Written in paragraph form

    • Advantage - detailed
    • disadvantage - time consuming
  20. 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
  21. 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
  22. Ethnicity
    the categorization of a group of people by a distinctive trait
  23. 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
  24. Culture Diversity
    the differences between groups of people in a certain geographical area, such as city state or country
  25. 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
  26. Cultural Awareness
    knowledge of various cultures beliefs and values
  27. Cultural Sensitivity
    Provide care to the pt and show respect for and incorporate the pts specific culture beliefs into your nursing care
  28. The nurse strives to understand anything that might influence the pts health including the pts:
    • perceptions
    • expectations
    • behaviors
    • decision-making processes
  29. Jewish
    Consult with family regarding whether or not you may touch the body after death
  30. Latter-day Saints
    • Sterilization is not permitted
    • Abortion is prohibited
  31. Seventh Day Adventists
    If anointment has taken place, avoid bath the pt for at least several hours
  32. Barriers to Health Care
    • Economics
    • Education
    • Geography
    • Language
    • Stereotyping
    • Prejudice and discrimination
    • Misunderstanding
  33. Stereotyping
    means that the person or group looks at another person or group through preconceived ideas or prefixed impressions
  34. Prejudice
    Discrimination or judgement about a person or group based on irrational suspicion or hatred of a particular group, race, or religion
  35. Discrimmination
    A type of unfair treatment of one or more persons or group
  36. 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
  37. Spiritualaity
    explains the spirit and the relationship of the spirit to the body, mind, and environment
  38. Spiritual Care
    Understanding of differences between spirituality, beliefs, and values
  39. Spiritual Distress
    Nursing diagnosis related to spirituality
  40. What is (are) responsible for the population explosion in America leading to an increase in the diversity of the citizens?
  41. What organization has worked to promote the pts right to culturally competent care in US hospitals?
    Joint Commission
  42. Nursing care that involves or combines the elements of more than one culture is..?
    Transcultural Care
  43. 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
  44. 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
  45. Muslims male circumcision is for what purpose?
  46. 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
  47. Which pt refuses blood transfusions due to religious beliefs?
    Jehovah witness
Card Set
Intro Ch 5 & 8
Intro chapter 5 & 8