Medical Records Basics
What is the chart or medical record considered in health care?
The legal record of care
What nursing process should documentation reflect?
Assessment, diagnosis, planning, implementation, and evaluation
Which documentation format shows trends in vital signs and blood glucose levels?
Flow charts
What report is given at the end of each shift to ensure continuity of care?
Change-of-shift report
What type of report documents accidents, medication errors, or falls?
Incident (variance) report
Who is allowed to access a client’s medical record?
Health care providers directly involved in the client’s care
Which type of data should be documented using the client’s exact words?
Subjective data
What documentation style records information in a story-like sequence?
Narrative documentation
What information should be ready before calling a provider with a telephone report?
Exact, relevant, and accurate client data
Should an incident report be referenced in the client’s medical record?
No
What are three purposes of medical records?
Communication, legal documentation, and billing (also education, research, auditing)
What is the nurse required to do regarding the timing of documentation?
Document as soon as possible after the event and never pre-chart
Which documentation system includes a database, problem list, care plan, and progress notes?
Problem-oriented medical record
What must a nurse do immediately after receiving a telephone prescription?
Repeat the prescription back to the provider
What type of language should be used when completing an incident report?
Factual language without judgment or opinion
Why do electronic health records pose privacy challenges?
Increased risk to confidentiality and information security
Which guideline requires documenting behavior rather than labeling it?
Objective, descriptive documentation without opinions
In SOAP charting, what does the “A” represent?
Assessment
Which actions are required for telephone prescriptions? (Select all that apply)
Have another nurse listen, repeat back the order, question inappropriate prescriptions, and obtain provider signature within required time frame
Which events require an incident report? (Select all that apply)
Medication errors, needlesticks, omission of prescription
What accrediting agency mandates computerized documentation systems?
The Joint Commission
Which legal documentation practices must nurses follow? (Select all that apply)
Date and time entries, use approved abbreviations, avoid correction fluid, sign entries properly
In DAR charting, what does the “R” stand for?
Response
What information must be included in a transfer (hand-off) report?
Diagnosis, plan of care, recent changes, vital signs, medications, allergies, equipment, advance directives, and discharge plan
What is the primary purpose of incident reports within health care facilities?
Quality improvement and prevention of future incidents