Documenting and Reporting

  1. What's in a client's chart? And what's are the principles behind a client's chart?
    • 1. A legal record
    • 2. Written documentation of the care received
    • 3. Provides for continuity of care
    • 4. Indicates compliance with your nurse practice act
    • 5. Evidence of quality of nursing care
  2. This pt record has database, problem list, plan of care, and progress notes. What is this pt record known as?
    Problem Oriented Medical Record
  3. This pt's record is traditional, each discipline with own documentation section. This record is known as...
    Source oriented Record
  4. This pt record has flowsheets, standards of care, ease of data retrieval. This record is known as...
    Electronic Record
  5. "Telling the story" is what kind of documentation system?
    Narrative charting
  6. Outline format is what kind of documentation system?
  7. What does SOAPIE stand for?
    • S ubjective data
    • O bjective data
    • A ssessment
    • P lanning
    • I ntervention
    • E valuation
  8. This documentation system only deals with "problems".
  9. What does PIE stand for?
    • P roblem
    • I intervention
    • E valuation
  10. This documentation system includes flow sheets and standards of care.
    Charting By Exception
  11. This documentation system is nursing process based (we use @NVCC)
    Focus charting
  12. This has multidisciplinary plan of care, identified outcomes for certain medical Dx, variance documentation, this documentation system is focuses on what's expected and it's known as...
    Critical Pathways
  13. What is are some examples of Critical Pathways?
    Pneumonia Pathway, Joint Replacement Pathway
  14. This documentation form includes demographics, ADL needs, treatments, and tests.
  15. This documentation form includes the graphic record, VS, I&O, med administration record, skin assessment, pt teaching, and restraints.
    Flow Sheets
  16. These forms include document assessment, care planned and provided, progress toward goals.
    Progress Notes
  17. What are the legal guidelines for charting?
    • 1. Write in black ink(photocopies better)
    • 2. Don't erase, white out, scratch out
    • 3. Don't discard legal records
    • 4. Don't chart before it's done (falsify records, fraud)
    • 5. Don't leave blank spaces
    • 6. Chart only for yourself
    • 7. Date and time each entry
    • 8. Sign each entry with first and last name and title, affiliation
    • 9. Don't share computer passwords
  18. When you write an error, what do u do?
    One line thru error, above write "omit" or "mistaken entry" and initials
  19. What are the ABCs of charting?
    • A ccurate
    • B rief and concise
    • C omplete
Card Set
Documenting and Reporting
How to accurately document and report as an RN.