Nursing Documentation Jeopardy

What is?

100

The word you use, in charting, when you see someone has fallen

Observed

200

The way you want to chart something rather than opinions or assumptions

be subjective or factual

300

Golden Rule of nursing documentation

If it isn't documented, then it didn't happen

WWYD?

100

Resident fell out of bed while trying to get up to go to the bathroom. Call light in reach but not on. BIMS 11.

Any intervention except education

200

Resident refuses repositioning and has a stage 3 pressure ulcer on buttock. BIMS 15.

Explain the risks and benefits. Resident can be educated 

300

Resident pulls of ventilator in order to get someone in the room. BIMS 8. 

Resident is not able to be educated

Chart This

100

When you chart that a resident has something wrong (pain, nausea, etc.) what else should you chart with the complaint?

Intervention and response

200

Why is it important to chart good descriptive, documentation?

To cover yourself and remind yourself about the scenario in case of going to a lawsuit

300

When can you chart that you "educated" a resident on something?

When BIMS is < or = to 13