Anything written or printed that you rely on as record or proof for authorized persons.
100
What is the correct color of ink for legal documents?
Black
100
As nurses, our documentation should reflect what?
Documentation should reflect the nursing process and your professional capabilities.
100
What is a Problem oriented medical record (POMR)?
Method of documentation that places emphasis on client’s problems.
100
What is a report?
Oral, written, or audiotape exchanges of information between caregivers, staff, other health professionals such as lab reports
200
What is the criteria for documentation?
-Accurate
-Comprehensive
-Flexible enough to retrieve critical data
-Maintain continuity of care
-Track client outcomes
-Reflect current standards of nursing practice
200
If you don't chart it...
...it didn't happen!
200
Language that portrays a negative attitude about the client include...
“Stubborn, drunk, weird, loony, or nasty.” These terms should be avoided.
200
What compiles a problem oriented medical record (POMR)?
-Data base
-Problem list
-Nursing care plan
-Progress notes
200
What is record?
Permanent written communication and a legal part of chart.
300
What is the purpose of documentation?
To communicate info to health care team and to
keep track of interventions and goals.
300
What are personal opinions?
These statements can be used as evidence for nonprofessional behavior or poor quality of care.
300
What is included in the documentation of medication administration?
The time you gave a medication, the administration route, and the patient's response.
300
What is a nursing history?
-Completed when a client is admitted
-Complete assessment
-Provides baseline data
300
What is half a nurse?
A student status upon completion of second semester nursing school.
400
What is contained in an SBAR?
What is happening at the present time?
What are the circumstances leading up to this situation? What do I think the problem is?
What should we do to correct the problem?
400
What if an order was questioned?
Record that clarification was sought.
400
How do you correct an error on your documentation?
Draw a single line through the error, write “error” and initial. Continue with corrected information.
400
What are graphic sheets?
-Allows doctors and nurses to easily and quickly enter data
-Vital signs
-Routine care
-Have codes to enter data
400
What is double jeopardy?
A chance to double your points!
500
What is effective documentation?
Ensures continuity of care, saves time, and minimizes the risk of errors.
500
How do you ensure accurate documentation?
-Chart only for yourself
-Time and date notes
-Never leave blank spaces or lines
-Record all facts
-Always sign your name
500
What is a "late entry" ?
If you remember an important point after you've completed your documentation, chart the information with a notation.
500
What are standardized care plans?
Pre-printed guidelines for patients with similar problems.
500
What is our signature?
First initial of your first name followed by full last name and BCSN