Nursing 151 Profession of Nursing

Profession of Nurs

110 cards   |   Total Attempts: 187
  

Cards In This Set

Front Back
Documentation
Any paper, electronic, information about a cient describing care or service to patient. Relied on for proof in legal situations. Reflects ongoing patient status, nursing process, care. Communication between disciplines and fellow workers.
Documents require what information?
- Assessment of the health status - Changes in function - S/S - Nursing actions, patients response - Advocacy undertaken - Visits by others - Date, Time, Signature and designation
Documenation should follow this criteria:
- Factual - Accurate - Complete - Current - Organized - Compliant with standards
Guidlines of documentation:
- Date/time - Signature - Sequence - Designation - Legible - Black or blue ink ONLY - Permanence - Accuracy - Terminology - Completeness - Correct Spelling - Concise - Legal prudence - Chart YOUR care ONLY - 24 hour clock - Approved abbreviations - No whiteout, one line cross out
Common errors in documenting
Faliure to document: - Administered meds - Allergies - Client care - On correct record - Discontinued meds - Transcribe orders incorrectly
Documentation Systems (5)
1) Narrative 2) Problem Oreiented Medical Records (POMR) or Health Care Records 3) Source Records 4) Charting by Exception 5) Critical Pathways or Care Plans
Narrative Key
Advantages Disadvantages
Documenation system KEY: Traditional, story like, specific patient condition and nursing care ADV: Flexible, easy, strongly conveys interventions and patient response DIS: Unstructured, repitition of info, time consuming
POMR Key
Advantages Disadvantages
Problem Oriented Medical Records Documentation System KEY: Based on patient's reason for seeking care, emphasis on problem, cosists of database, problem list, plan of care, progress notes - SOAP (Subjective, Objective, Assessment, Evaluation) - PIE (Problem, Intervention, Evaluation) - DAR (Data, Action, Response) ADV: Focus on patient problem, easy info retrieval, clear interventions, reflects nursing process DIS: Time consuming, negative focus
Source Records Key
Advantages Disadvantages
Documentation System KEY: Separate sections of chart for each discipline ADV: Caregivers can locate specific records DIS: Same problem throughout
Charting by Exception Key
Advantages Disadvantages
Documentation System KEY: Non- traditional, significant or abnormal findings only charted, all standards assumed met if not documented, unique flow sheets, standard care plans, and progress notes ADV: Evaluate and document findings consistently, eliminates repitition, concise DIS: Legality issues, patient/family perspective
Critical Pathways or Care Plans Key
Documentation System KEY: Identifies epected outcomes for eahc day of care/type focus on positive and negative outcomes
Critical incident
Aka Adverse event - Any event not part of routine care that results in injury or risks client injury - Must be reported
Change of shift reporting
- Face to face - Tape recorded - Telephone and verbal (Not allowed as Nursing Student), would not advise to do this kind of reporting
Parameters of reporting
- Confidential - Clear - Concise - Accurate - Facts - Logical sequence - Highlight important information - Avoid bias
Concepts
Idea or mental image of a phenomena; building blocks to theory - Concrete - measureable, able to see - Abstract - immeasurable, independent of time, place (ex hope and power)