Nursing Process, Physical Assessment, Documentation

What are the five purposes of patient records?

Documented communication, permanent accountability record, legal record, teaching, and research/data collection.

Audit

Review of patient records and care documentation.

DRG

Diagnosis-Related Group; classification based on diagnosis, procedures, and other information.

Nurses' notes

Record of nursing observations, care provided, and patient responses.

EHR

Electronic Health Record; digital record of patient health information.

PHR

Personal Health Record; health information maintained or managed by the patient.

COW

Computer on Wheels.

Patient portal

Allows patients to access portions of their health records.

NKA

No Known Allergies.

NKDA

No Known Drug Allergies.

When should nurses chart?

As soon as possible after providing care, never before.

What should nursing documentation be?

Clear, concise, complete, accurate, objective, and timely.

Who is responsible for the initial admission nursing history and care plan?

Registered nurse (RN).

What information belongs on patient documents?

Correct patient identifiers, date, and time when appropriate.

What should nurses avoid in charting?

Opinions, blame, guesses, assumptions, and vague phrases.

Who may a nurse chart for?

Only themselves; document personally provided care and observations.

How are handwritten charting errors corrected?

Follow facility policy; do not erase or use correction fluid.

What type of ink is used in handwritten records?

Permanent black ink, according to the slides.

What should be documented after giving pain medication?

Patient response and effectiveness of the medication.

What should be documented when a patient leaves the unit?

Departure and return times and method of transportation.

Late entry

Documentation entered after the event and identified as late.

What abbreviations are acceptable in documentation?

Only facility-approved medical abbreviations.

What should be documented if an order needs clarification?

That clarification was sought, including the appropriate details.

Legal importance of documentation

Provides evidence of assessments, interventions, responses, and care.

ISBAR

Identification, Situation, Background, Assessment, Recommendation.

I in ISBAR

Identification.

S in ISBAR

Situation.

B in ISBAR

Background.

A in ISBAR

Assessment.

R in ISBAR

Recommendation.

Narrative charting

Story-form description of patient findings, care, and responses.

POMR

Problem-Oriented Medical Record.

SOAPIER

Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision.

S in SOAPIER

Subjective information reported by the patient.

O in SOAPIER

Objective information observed or measured.

A in SOAPIER

Assessment or interpretation of patient findings.

P in SOAPIER

Plan for patient care.

I in SOAPIER

Interventions performed.

E in SOAPIER

Evaluation of patient response.

R in SOAPIER

Revision of the plan as needed.

Focus charting

Documentation organized around a specific patient concern.

DAR

Data, Action, Response.

DARE

Data, Action, Response, Education.

PIE

Problem, Intervention, Evaluation.

Charting by exception

Primarily documents findings that deviate from established norms.

Flow sheet

Organized form for repeated assessments and measurements.

Clinical pathway

Multidisciplinary plan coordinating care for a patient group.

Incident report

Record of an unusual event or occurrence.

0700

7:00 AM.

1930

7:30 PM.

Six phases of nursing process

Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, Evaluation.

ADPIE

Assessment, Diagnosis, Planning, Implementation, Evaluation.

Assessment phase

Collect subjective and objective patient information.

Diagnosis phase

Identify the patient's nursing problems.

Outcomes identification

Establish expected, measurable patient outcomes.

Planning phase

Set priorities and select nursing interventions.

Implementation phase

Perform the planned nursing interventions.

Evaluation phase

Determine whether patient goals were achieved.

Subjective data

What the patient reports, feels, or experiences.

Objective data

What the nurse observes or measures.

Cue

Information indicating the need for further assessment.

Primary source of assessment data

The patient.

Secondary sources of assessment data

Family, medical history, and other records.

Methods of collecting assessment data

Interview and physical examination.

Nursing diagnosis

A patient problem identified through nursing assessment.

NANDA-I

Standardized nursing diagnostic terminology.

Three parts of an actual nursing diagnosis

Problem, Etiology, Signs and Symptoms.

Etiology

Cause or related factor contributing to the problem.

R/T

Related to; connects the nursing problem with its etiology.

AEB

As evidenced by; introduces supporting signs and symptoms.

Risk nursing diagnosis

Identifies a potential problem that has not yet occurred.

Does a risk diagnosis include AEB?

No; the problem has not occurred, so defining symptoms are absent.

Medical diagnosis

Identifies a disease or medical condition.

Collaborative problem

Problem requiring monitoring and collaboration with other healthcare professionals.

Goal statement

Specific, measurable patient behavior expected within a time frame.

Priority setting

Ranking patient problems according to urgency and needs.

What needs receive priority?

Life-threatening and physiological needs.

Actual versus risk problems

Actual problems may take priority over potential problems.

Nursing intervention

Action selected to help achieve a patient outcome.

NIC

Nursing Interventions Classification.

NOC

Nursing Outcomes Classification.

Goal achieved

The expected outcome has been met.

Goal partially achieved

Some but not all expected results have been met.

Goal not achieved

The expected outcome has not been met.

Critical thinking in nursing

Using clinical knowledge and reasoning to make care decisions.

Evidence-based practice

Using research evidence, clinical expertise, and patient preferences to guide care.

Sign

Objective finding that can be observed or measured.

Symptom

Subjective experience reported by the patient.

Disease

Disturbance of normal body structure or function.

Etiology of disease

Cause or origin of a disease.

Hereditary disease

Disease associated with inherited characteristics.

Congenital condition

Condition present at birth.

Infectious disease

Disease caused by invading microorganisms.

Degenerative disease

Condition involving progressive deterioration.

Neoplastic disease

Disease involving abnormal tissue growth.

Four disease risk categories

Genetic/physiologic, age, environment, and lifestyle.

Modifiable risk factor

Risk factor that can be changed, such as smoking.

Nonmodifiable risk factor

Risk factor that cannot be changed, such as age.

Acute disease

Condition of relatively short duration.

Chronic disease

Condition that persists for a long period.