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Chapter 3 & 5

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what is Chart (health care record)

it is a legal record that is used to meet the many demands of the health, accreditation, medical insurance and legal system.

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Chapter 3 & 5 - Details



106 questions
What is Chart (health care record)
It is a legal record that is used to meet the many demands of the health, accreditation, medical insurance and legal system.
Documenting the type of intervention, the time care was rendered, and the signature and the title of the person providing care is essential.
What are the 5 purposes of documentation
Documented communication, permanent record for accountability, legal record of care, teaching, research and data collection
People appointed to examine patients charts and health records to assess quality of care
Peer review
An appraisal by professional coworker of equal status
Quality assurance, assessment, and improvement
An audit in health care that evaluates services provided and the results achieved compared with accepted standards
Diagnosis- related groups ( DRGs)
Prospective payment system classified by age, diagnosis, surgical procedures, length of stay, etc
What is the nursing process ADPIE
Assessment, diagnosis, outcome identification/planning, implementation, evaluation
Nursing notes
The form of the patients charts on which nurses record their observations, the care given, and the patients responses
SBAR()R stand for
Situation, Background, Assessment, Recommendation, (Read back)
What does EHR increase
Efficiency, consistency, and accuracy and decrease cost
What isa benefit of EHR
Ability for all health care providers to view a patients records, encouraging increased continuity of care
Point of care POC
Computer input only at the nurses station, some facilities have bedside systems and hand held systems
COW computers on wheels
Poc charting system are housed on wheeled carts
A classified system of technical or scientific names or terminology
The study of information processing
Personal health record (PHR)
Is an extension or the EHR that allows patient to input their information into an electronic database
What is SBAR considered
A safety measure in preventing errors from poor communication during interaction between health care personnel, the communication from one shift to the next, or when a nurse phones a health care provider with information about a patient
When do you use the R in SBARR
When you take a phone order or when talking to the Dr. always Read back what they said to ensure what the nurse heard was correct
What does the LVN need to ensure when charting
Information is clear, concise, complete and accurate
Traditional (block) chart
Is decided into sections or blocks. emphasis is placed on specific sections( or sheets for non computerized charts) of information.
Narrative charting
Where the nurse records patient care in a descriptive form, in chronological order
Problem-oriented medical record (POMR)
Is organized according to the scientific problem-solving system or method
A large store or bank of information, such as informing the patient nurse diagnosis
Problem list
Active, inactive, potential, and resolved problems served as the index for chart documentation
Acronym for 7 different aspects of charting for notes on specific problems
Information is what the patient states or feels; only the patient can tell this information
Information is what the nurse can measure or factually describe
Refers to analysis or potential diagnosis of the cause of the patients problems or needs
Is the general statement of the plan of care being given or action to be taken
I-intervention or implementation
Is the specific care given or action taken
Is an appraisal of the response and effectiveness of the plan
Includes the changes that may be made to original plan of care
Consolidate patient orders and care needs in a centralized, concise way
Nursing care plan
Outlines the proposed nursing care based on the nursing assessment and the identified problems to provide continuity of care
Incident report
Form used to document any event not consistent with routine operation of health care unit or the routine care of a patient
What do you include in incident report
Objective, observed information
What do you not include in an incident report
Do not admit liability and unnecessary information
When charting why do you not mention an incident report
Doding so makes it easier for an attorney to request that documentation for a court case
24 hr patient care records
Provide foundation for acuity chart system
Acuity charting
Uses a score that rates each patient by severity of illness ( level 1 requires almost all of your time like a patient out of surgery level 5 minimal time like just passing meds)
What is one benefit of acuity charting
The ability to determine efficient staffing patterns according to the acuity levels of the patient on a particular nursing unit
Discharge summary
Form that provides information that pertains to the patients continued health care after discharge
Clinical (critical) pathways
Allow staff from all discipline(dr, pt, to,nurses etc) to develop standardized, integrated care plans for a projected length of stay for a specific case type (diagnosis)
Home health care documentation
Document in detail any procedures, treatments, medications administered and response to these interventions , education and demonstrating of leaning
What does OBRA ( ominous budget reconciliation act) require
Regulated standards for resident assessments, individualized care plans, and qualifications for health care providers
Who owns the healthcare record or chart of the patient
The institution or healthcare provider
How can a lawyer get the patients records
With the patients written consent
What does student nurses need to know
No information is to leave the clinical site, any documents with patient identifiers must be safely guarded at all times in the facility, must shred all papers or notes with patient information on it prior to leaving the facility
What needs to be done prior to faxing information
Verify the number before sending any patient information
Nursing process
Is a systematic method by which nurses plan and provide care for patients
A systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care
Definition of nursing
Protection, promotion, optimization of health and abilities, prevention of illness & injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment to the human response, advocate in the care of individuals, families, groups, communities, and population
Outcome and goals are something that a person strives to achieve
Is a piece or pieces of data that often indicate that an actual or potential problem has occurred or will occur
Subjective data
Information that the patient provides ( hide information until patient shares information)
Objective data
Are observable and measurable signs
Biographic data
Provides information about the facts or events in a persons life
A large stor or bank of information
Is to identify the type and cause of a health condition
Focused assessment
When patient is critically ill, disoriented, or unable to respond. a focused assessment is used to gather information about a specific health assessment
Nursing diagnosis/ patient problem statement
Is a type of health problem that can be identified by the nurse
To reflect nursing diagnosis terminology used around the world
NANDA (I) acronym means what
North American Nursing Diagnosis Association International
Patient problem statement
Patient problems may be actual or potential can use adjective ( inability, insufficient, impaired, and willingness
Actual patient problem statement
An actual patient problem statement identifies health-related problems that exist and are discovered during the nursing assessment
Potential patient problems
Are written as two part statements 1: the patient problem statement with adjective "potential" in front of it and 2: then risk(s) factors
Defining characteristics
Are the clinical cues, signs, and symptoms that furnish the evidence that the problem exists
Collaborative problems
Are health- related problems that the nurse anticipates based on the condition or diagnosis of a patient
Medical diagnosis
Is the identification of a disease or condition with evaluation of physical signs, symptoms, patient interview, lab test, diagnostic procedures, review of medical records and patient history
Goal statement indicates the degree of wellness desired, expected, or possible for the patient to achieve and contains a patient goal statement
Phase of the nursing process, priorities of care are established and nursing interventions are chosen to best address the patient problem statement
Nursing interventions
Are those activities that promote the achievement of the desired patient goal
The nurse and other members of the team put the established plan into action to promote goal achievement
Is determination made without the extent to which the established goals have been achieved
Physician-prescribed interventions
Are those actions ordered by a physician for a nurse or other health care professional to perform
Nurse-prescribed interventions
Ae the actions that a nurse is legally able to order or begin independently
What are nursing interventions often aimed at
Reducing or eliminating the cause factor
Properly written nursing interventions include what
Specific for the problem, realistic for the patient, compatible with the medical plan of care, and based on specific evidence-based principles
The nurse and other members of the team put established plan into action to promote goal achievement
Is a determination made about the extent to which the established goals have been achieved
Standardized language
Terms that have the same definition and meaning regardless of who uses them
Nursing sensitive outcomes
Standardized system with an organized structure to name and measure
Nursing Interventions Classification
Nursing Outcome Classification
Managed care
Refers to the health care system that have control over primary health care services and attempt to trim down healthcare costs by reducing unnecessary or overlapping services
Case management
Encompasses planning, coordination of care, and patient advocacy in providing quality, cost-effective outcomes for the patient
Clinical pathways
Is a multidisciplinary plan that incorporates evidence-based practice guidelines for high-risk, high cost types, of cases while providing for optimal patient outcomes maximized clinical efficiency
If a patient does not achieve the projected outcome
Define critical thinkers
Question information, conclusions, and points of view and look beneath the surface
The NLN defines critical thinking for nurses as what
A discipline-specific, reflective reasoning process that guides a nurse in generating, implementing, and evaluating approaches for dealing with client care and professional concerns
Why is critical thinking essential
To provide quality nursing care for patients of various situations
How does the ANA define evidence-based practice
A scholarly systematic problem-solving paradigm that results in the delivery of high-quality health care
Definition of the nursing process
Is a brainwork by which to organize individualized nursing care
How many types of data are there
Two, primary and secondary
What is primary data
From the patient if alert and oriented
What is secondary data
Include family members, significant others, medical records, diagnostic procedures, and previous nursing notes
Who can provide a medical diagnosis
Physician or other medical qualified health care provider such as nurse practitioner
What is the first method of data collection
The nurse conducts an interview, the nursing health history, to obtain information about the patients health history