Documentation in Nursing Care

These flashcards cover key concepts regarding documentation practices in nursing care, emphasizing the importance of accurate record-keeping and the regulations that guide it.

What is documentation in nursing care?

The act of recording pertinent medical information in a patient’s medical record.

What forms can documentation take?

Handwritten on a paper chart or keyboarded into an electronic medical record.

What is the purpose of documentation?

Continuity of care, providing a permanent record of care, accountability, and legal documentation.

What does 'not charted, not done' mean?

If something is not documented, it is considered that it was not performed.

Whose property is the original medical record?

The property of the hospital or facility, but the information belongs to the patient.

What rights does the HIPAA grant patients regarding their medical record?

The right to view and obtain a copy of the medical record.

What is confidentiality in documentation?

The maintenance of privacy by not sharing privileged information with unauthorized parties.

What should incident reports include?

Objective information about out-of-the-ordinary occurrences and actions taken.

What types of events prompt the creation of incident reports?

Medication errors, patient injuries, and safety hazards.

What is a care plan in documentation?

A document outlining patient’s problems, interventions, and effectiveness of each intervention.

What should be avoided when recording in a patient chart?

Taking shortcuts, using unapproved abbreviations, and lack of accuracy.

What are the two types of medical records?

Source-oriented and problem-oriented medical records.

How is a problem-oriented health record different from a source-oriented record?

It is organized around the patient’s individual problems rather than data sources.

What types of data should be documented?

Physical and emotional assessments, vital signs, and all patient care and interventions.

What is narrative charting?

A method that tells the story of a patient’s experience during their hospital stay.

What data is important to document regarding patient education?

Teaching needs, information taught, methods of teaching, and effectiveness.

What is an Electronic Health Record (EHR)?

A record of an individual’s lifetime health information that is easily updated and transferable.

What are the benefits of using an EHR?

Reduces errors and improves communication among health-care staff.

What are the confidentiality requirements for EHR?

Need for ID and password; violations can lead to civil and criminal penalties.

What documentation requirements exist for long-term care?

Frequency may differ; may involve paper charts and tools like the Kardex.

What color ink should be used for paper documentation?

Black or blue ink.

What must be included with each documentation entry?

Date and time along with a clear signature.

What assessments are required for home health documentation?

Outcome and Assessment Information Set (OASIS) and regulated audits.

What are common documentation mistakes that increase malpractice risk?

Failure to document assessments, medications, and pertinent health history.