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NRS Documentation
test 1
Question | Answer |
---|---|
Purpose of the chart | communication, permanent record for accountability, peer review, reimbursement, legal record of care, teaching tool, and research and data collection |
Types of patient records | source-oriented and problem-oriented |
source-oriented chart | each healthcare discipline documents in their own section |
Problem-oriented chart | based on scientific problem-solving method; organized according to the health problem |
problem oriented chart includes | database,problem list, plan of care, and progress notes (everybody documents here) |
methods of charting | narrative style, SOAPE/SOAPIER, Focus, PIE, charting by exception |
charting by exception | only abnormal assessment findings are documented; effort to decrease length and repetition |
PIE charting | Problem Intervention Evaluation |
Focus charting DARE | Data Action Response Education |
SOAPE/SOAPIER charting | Subjective Objective Assessment Plan Evaluation Intervention Revision |
Narrative charting | descriptive form including pt. problem, care and treatment provided; as well as pt. response |
computer charting pros/cons | PROS fast, legible, auto date/time CONS can risk confidentiality, can be hard to make corrections if not made quickly |
T or F never use military time | False |
00:00= | midnight or 12am |
12:00= | 12pm or noon |
18:00= | 6pm |
23:00= | 11pm |
1am | 01:00 |
6am | 06:00 |
T or F Rn is responsible for initial assessment upon admission | True |
T or F any sheet patient info is documented on may only include the patient date of birth | False. It should have their at least their name on every page |
T or F when in doubt write it out | True |
when giving medications, especially PRN... | Always chart follow-up response 30 minutes after |
T or F Empty lines in a chart are okay if there is nothing to note | False. Any skipped lines or empty lines should at least have a line drawn through them to avoid additions at later times. |
T or F chart as soon as you can, even if it is prior to giving care | False. only chart after care is given and as soon as possible after |
Do you have to chart the type of transportation device used to transfer or discharge a pt.? | yes. |
Can you chart deviations without and explanation? | No. there needs to always be an explanation of any deviations from the original care plan. |
should you document any time the physician was contacted? | Yes. |