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Nursing Documentation Principles
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100

The 4 elements of documentation

What is...


Factual: Subjective and objective data

Accurate and concise: Document facts and information precisely (what the nurse sees, hears, feels, smells) without any interpretations of the situation. Unnecessary words and irrelevant detail are avoided. Exact measurements establish accuracy. Only abbreviations and symbols approved by The Joint Commission and the facility are acceptable.

Complete and current: Document information that is comprehensive and timely. Never pre-chart an assessment, intervention, or evaluation. Timely documentation occurs as soon after the observation or event as possible. 

Organized: Communicate information in a logical sequence.

100

    Grinding of teeth during sleep

What is...

Bruxism

100

This type of charting includes a more detailed and organized method when documenting client care. Sections of the medical record are divided, and the ability to share among the interdisciplinary team can be limited. 

What is...

Problem-oriented medical record (POMR)

100
"I feel a little short of breath"
What is Subjective DATA?
100

This is a cutaneous skin stimulation to interrupt pain pathways, provide cold for inflammation and heat to increase blood flow to reduce stiffness

What is...

TENS unit (Transcutaneous Electrical Nerve Stimulation) portable device provides temporary pain relief for various conditions by interfering with pain perception, making it an effective alternative for managing pain without medication 

200

When an incident occurs, what information is documented, and what information isn't documented?

Name 3 for each

What is...

Vital signs, any additional findings, notification of the provider, treatments or procedures the provider prescribes, and the client's response.

What is not...

Judgement, assumptions, conclusions, or blame

200

Sudden attacks of sleep that are often uncontrollable. It can occur at inappropriate times and increases the risk of injury. With hallucinations, sleep-wake cycles. 

What is...

Narcolepsy

200

This type of charting centers on a client’s specific problem. When using focused charting, three areas that are required for documentation are...

What is...

DAR - data, action, and response.

200
Patient positioned in high Fowler's position.
What is a nursing ACTION/intervention?
200

Nonverbal signs of pain

What is...

Restlessness, grimacing, clenching, anxiety, tightly closing eyes, biting bottom lip

300

The purpose of electronic documentation

What is...

  • Medical records include communication, legal documentation, financial billing, education, research, and auditing.
  • The purpose of reporting is to ensure continuity of care and enhance communication among all team members who care for the same clients, thereby promoting client safety.
300

This dysfunction in the respiratory control center of the brain fails to trigger breathing during sleep, as a result of a brain injury or opioid overdose.

What is...

The CNS

300

This type of charting includes an intervention demonstrated by the nurse to address the client’s problem. 

What is...

PIE - Problem, interventions, and evaluation

300
Patient's respiratory rate has decreased to 16 and effort is now unlabored.
What is a patient RESPONSE/outcome?
300

What pain is caused by somatic origin or visceral origin, due to damage to bone, joints, muscle, skin, or connective tissue? 

What is...

Nociceptive pain, like an injury, sprain, or strain.

400

This is completed by a registered nurse in a long-term care setting and contains an evaluation of each resident's assessment, including their cognitive and physical status. These forms are maintained at the facility for state compliance. 

What is...

minimum data set (MDS)

400

Which nursing actions promote better sleep habits.

Must name 5

  • Help clients establish and follow a bedtime routine.
  • Limit waking clients during the night.
  • Promote a quiet hospital environment, avoid stimuli like TV's.
  • Help with personal hygiene needs or a back rub prior to sleep to increase comfort. 
  • Consider continuous positive airway pressure (CPAP) devices for clients who have sleep apnea.
  • Consult the provider about trying sleep-promoting over-the-counter products (melatonin, valerian, chamomile).
  • As a last resort, suggest that the provider prescribe a pharmacological agent. Medications 
  • Adjust inpatient routines when possible, to conform with clients’ home routines (bathing, bedtime).
400

This type of charting utilizes standardized forms that identify norms and enable the selective documentation of deviations from those norms. 

What is...

Charting by exception

400
V/S: 148/86, 110, 22, 99.9
What is Objective DATA
400

This is a medication delivery system that allows clients to self-administer safe doses of opioids. Small, frequent dosing ensures consistent plasma levels.

What is...

Patient-controlled analgesia (PCA) 

To prevent inadvertent overdosing, the client is the only person who should push the PCA button

500
What are the legal guidelines for documentation


Must provide 4

What is...

  • Begin each entry with the date and time.
  • Record entries legibly, in non-erasable black ink, and do not leave blank spaces in the nurses’ notes.
  • Do not use correction fluid, erase, scratch out, or blacken out errors in the medical record. Make corrections promptly, following the facility’s procedure for error correction.
  • Sign all documentation as the facility requires, generally with name and title.
  • Documentation should reflect assessments, interventions, and evaluations, not personal opinions or criticism about client or other health care professionals’ care.
500

Factors that Interfere with Sleep

Must provide 5

Physiologic disorders: Can require more sleep or disrupt sleep (sleep apnea, nocturia)

Current life events: Traveling more, change in work hours

Emotional stress or mental illness: Anxiety, fear, grief

Diet: Caffeine consumption, heavy meals before bedtime

Exercise: Promotes sleep if completed 3  hr before bedtime, otherwise can disrupt sleep

Fatigue: Exhausting or stressful work makes falling asleep difficult.

Sleep environment: Too light, the wrong temperature, or too noisy (children, pets, loud noise, snoring partner)

Medications: Some can induce sleep but interfere with restorative sleep. Others (bronchodilators, antihypertensives) cause insomnia.

Substance use: Nicotine and caffeine are stimulants. Caffeine and alcohol tend to cause night awakenings.

500
Units, Daily, Every other day, Morphine Sulfate, Magnesium Sulfate, and International Units
What words are NOT to be abbreviated?
500

Patient stated his pain has decreased to a 3 on a scale from 0 to 10.

What is a patient RESPONSE/outcome?

500

This....intense, shooting, burning, or described as “pins and needles.” Also includes phantom limb pain, pain below the level of a spinal cord injury, and diabetic injuries

What is...

Neuropathic pain