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101 Exam 2 – Key Terms & Learning Objectives Ch. 19 – Documenting and Reporting Key Terms:
1. bedside report: a. standardized, streamlined shift report system at the bedside; helps ensure the safe handoff of care between nurses by involving the patient and family 2. change-of-shift report: a. communication method used by nurses who are completing care for a patient to transmit patient information to nurses who are about to assume responsibility for continuing care; may be exchanged verbally in a meeting or audiotaped 3. charting by exception (CBE): a. shorthand method for documenting patient data that are based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes 4. confer: a. to consult with someone to exchange ideas or to seek information, advice, or instructions 5. consultation: a. process in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution 6. critical/collaborative pathway: a. case management plan that is a detailed, standardized plan of care developed for a patient population with a designated diagnosis or procedure; it includes expected outcomes, a list of interventions to be performed, and the sequence and timing of those interventions 7. discharge summary:
a. description of where the patient stands in relation to problems identified in the record at discharge; documents any special teaching or counseling the patient received, including referrals
8. documentation: a. written, legal record of all pertinent interventions with the patient—assessments, diagnoses, plans, interventions, and evaluations 9. electronic health record (EHR): a. digital version of a patient’s chart that may contain the patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results 10. flow sheet: a. graphic record of abbreviated aspects of the patient’s condition (e.g., vital signs, routine aspects of care) 11. focus charting: a. a documentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care; the focus may be a patient strength or a problem or need; the narrative portion of focus charting uses the data (D), action (A), response (R) format 12. graphic record: a. form used to record specific patient variables 13. handoff: a. a nurse’s report to another nurse or health care provider about a patient’s status and progress 14. health information exchange (HIE): a. an electronic system that allows physicians, nurses, pharmacists, other health care providers, and patients to appropriately access and securely share a patient’s vital medical information 15. incident report:
a. documentation system that does not develop a separate care plan; the care plan is incorporated into the progress notes in which problems are identified by number, worked up using the problem (P)–intervention (I)–evaluation (E) format, and evaluated each shift
24. problem-oriented medical record (POMR): a. documentation system organized according to the person’s specific health problems; includes database, problem list, plan of care, and progress notes 25. progress notes: a. any of a variety of methods of notes that relate how a patient is progressing toward expected outcomes 26. purposeful rounding: a. proactive, systematic, nurse-driven, evidence-based intervention that helps nurses anticipate and address patient needs 27. read-back: a. a process in which a nurse or other health care provider repeats a verbal order back to a physician to ensure that it was correctly heard and interpreted 28. referral: a. process of sending or guiding someone to another source for assistance 29. SOAP format: a. method of charting narrative progress notes; organizes data according to subjective information (S), objective information (O), assessment (A), and plan (P) 30. source-oriented record: a. documentation system in which each health care group records data on its own separate form 31. variance charting: a. documentation method in case management when a patient fails to meet an expected outcome or when a planned intervention is not implemented that records unexpected events, the cause for the event, actions taken in response to the event,
and discharge planning when appropriate; typically used for variances that affect quality, coast, or length of stay; also called occurrence charting
32. variance report: a. tool used by health care facilities to document the occurrence of anything out of the ordinary that results in or has the potential to result in harm to a patient, employee, or visitor; also called an incident report or occurrence report Learning Objectives:
- List guidelines for effective documentation, including those of the American Nurses Association. Answer: The ANA Standards identify the following characteristics of effective documentation: o Accessible o Accurate, relevant, and consistent o Auditable; clear, concise, and complete o Legible/readable (particularly in terms of the resolution and related qualities of HER content as it is displayed on the screens of various devices) o Thoughtful o Timely, contemporaneous, and sequential o Reflective of the nursing process o Retrievable on a permanent basic in nursing specific manner
- Identify measures to protect confidential patient information. Answer:
o Diagnostic and therapeutic orders o Care planning o Quality process and performance improvement o Research o Decision analysis o Education o Credentialing, regulation, and legislation o Legal documentation o Reimbursement o Historical documentation
- Compare and contrast different methods of documentation, including electronic health records, source-oriented records, problem-oriented medical records, PIE charting, focus charting, charting by exception, and the case management model. Computerized documentation and electronic health records: o With computer-based records or electronic health records (EHRs), data can be distributed among many caregivers in a standardized format, allowing them to compare and uniformly evaluate patient progress easily. - Besides tracking the progress of individual patients, computerized outcome information can aid in comparing the progress of groups of patients with similar diagnoses – these results will contribute to research, education, and ultimately, better and more efficient nursing practice. o Terms used to discuss electronic records in health care: (pg. 466) - Health care smart card - Electronic health record (EHR) - Electronic medical record (EMR) - Health information exchange (HIE) - Electronic database Source-oriented records
o Many nurses, especially in rural and underserved areas, continue to practice in settings that do not use EMRs – traditional paper records are still used in such settings, in a variety of formats. (pg. 468 for different types of source-oriented forms) o A source-oriented record is a paper format in which each health care group keeps data on its own separate form.
- Sections of the record are designated for nurses, health care providers, laboratory, x-ray personnel, and so on.
- Notations are entered chronologically, with the most recent entry being nearest the front of the record. o Advantage: each discipline can easily find and chart pertinent data o Disadvantage: data are fragmented, making it difficult to track problems chronologically with input from different groups of professionals. Problem-oriented medical records o AKA POMR, or problem-oriented record, is organized around a patient’s problems rather than around sources of information.
- Health care professionals record information on the same forms.
- The SOAP format (Subjective data, Objective data, Assessment [the caregivers judgment about the situation], Plan) is used to organize entries in the progress notes of the POMR. PIE charting: problem, intervention, evaluation o The PIE charting system is unique in that it does not develop a separate care plan – the care plan is incorporated into the progress notes. o In this documentation system, a patient assessment is performed and documented at the beginning of each shift using preprinted fill-in-the- blank assessment forms (flow sheets).
- Patient problems identified in these assessments are numbered, documented in the progress notes, worked up using the Problem, Intervention, Evaluation (PIE) format, and evaluated each shift.
o Patient records must communicate the patient’s problems or diagnoses; related goals, outcomes, and interventions; and progress or resolution of the problems. Critical/collaborative pathways: o The critical/collaborative pathway is an abbreviated summary of key information taken from the more detailed case management plan. Progress notes: o The purpose of progress notes is to inform caregivers of the progress a patient is making toward achieving expected outcomes.
- Method used to record the patient’s progress depends on the documentation system being used – common examples include narrative nursing notes, SOAP notes, PIE notes, focus charting, CBE, and the care management model. Flow sheets: o Documentation tools used to efficiently record routine aspects of nursing care.
- Well-designed flow sheets enable nurses to quickly document the routine aspects of care that promote patient goal achievement, safety, and well-being. Discharge summary: o When a patient is discharged from care or transferred from one unit, institution, or facility to another, a discharge summary should be written that concisely summarizes the reason for treatment rendered, the patient’s condition on discharge or transfer, and any specific-pertinent instructions given to the patient family. Home care documentation: o Documentation of home health care visits that reports the patient’s progress serves multiple purposes.
- Sent to the attending health care provider with a request for signed medical orders to continue treatment, these records ensure continuity of care.
- Sent to third-party payers, they establish the need for continuing home care with continued reimbursement for necessary services.
- Document nursing interventions completely, accurately, currently, concisely, and factually—avoiding legal problems.
- Describe the nurse’s role in communicating with other health care professionals by reporting. A nurse’s shift or handoff report or nursing note might communicate the progress a patient is making toward goal achievement. The Institute for Healthcare Improvement is promoting the ISBAR communication technique as a framework for communication between members of the health care team about a patient’s condition. o Identity/Introduction: communicate who you are, where you are, and why you are communicating. o Situation: communicate what is occurring and why the patient is being handed off to another department or unit. o Background: explain what led up to the current situation and put in context if necessary. o Assessment: give you impression of the problem. o Recommendation: explain what you would do to correct the problem. Ch. 29 – Medications Key Terms: 1. absorption:
13. half-life: a. the amount of time it takes for half a dose of a drug to be eliminated from the body 14. idiosyncratic effect: a. unusual, unexpected response to a drug that may manifest itself by overresponse, underresponse, or response different from the expected outcome 15. inhalation: a. (1) act of breathing in; synonym for inspiration; (2) administration of a drug in solution via the respiratory tract 16. intradermal injection: a. injection placed just below the epidermis 17. intramuscular injection: a. an injection into deep muscle tissue, usually of the buttock, thigh, or upper arm 18. intravenous route: a. injection of a solution into the vein 19. medication reconciliation: a. process of creating an accurate list of all medications a patient is taking, including drug name, dosage, frequency, and route, and comparing the list to the physician’s admission, transfer, or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital 20. metabolism: a. (1) chemical changes in the body by which energy is provided; (2) breakdown of a drug to an inactive form; also referred to as biotransformation 21. parenteral: a. outside of intestines or alimentary canal; popularly used to refer to injection routes 22. peak level: a. highest plasma concentration of a drug 23. pharmacodynamics: a. process by which drugs alter cell physiology and affect the body 24. pharmacogenetics:
a. the study of how genetic variation affects an individual’s response to drugs
25. pharmacokinetics: a. movement of drug molecules in the body in relation to the drug’s absorption, distribution, metabolism, and excretion 26. pharmacology: a. study of actions of chemicals on living organisms 27. pharmacotherapeutics: a. dynamic that achieves the desired therapeutic effect of the drug without causing other undesirable effects **28. piggyback delivery system:
- placebo:** a. Latin word meaning, “I shall please”; an inactive substance that gives satisfaction to the person using it 30. PRN order: a. “as needed” order for medication 31. stat order: a. single order carried out immediately 32. subcutaneous injection: a. injection into the subcutaneous tissue that lies between the epidermis and the muscle 33. synergistic effect: a. combined effect of two or more drugs is greater than the effect of each drug alone 34. teratogenic: a. known to have potential to cause developmental defects in the embryo or fetus 35. therapeutic range: a. that concentration of drug in the blood serum that produces the desired effect without causing toxicity 36. topical application: a. application of a substance directly to a body surface
Generic name: identifies the drug’s active ingredient; the name assigned by the manufacturer that first develops the drug. o The official name is typically the generic name. Trade name: also referred to as the brand name, is selected by the pharmaceutical company that sells the drug and is protected by trademark – a drug can have several trade names when produced by different manufacturers. Ex. Acetaminophen (generic name) has trade names such as Tylenol, Tempra, and Liquiprin. o Types of drug preparations:
- Drugs are available in many forms, or preparations – oral, topical and parenteral administration. Capsule, elixir, enteric coated, extended release (ER), liniment, lotion, lozenge, ointment, pill, powder, solution, suppository, suspension, syrup, tablet, transdermal patch - SEE PAGE 823 FOR DESCRIPTION OF EACH!!! o Drug classification:
- Drug classifications, or drug classes, refer to groups of drug that share similar characteristics – drugs are classified in two primary ways: pharmaceutical class and therapeutic class. Pharmaceutical class refers to the mechanism or action (MOA), physiologic effect (PE), and chemical structure (CS) of the drug. Therapeutic class refers to the clinical indication for the drug or therapeutic action (ex. Analgesic, antibiotic, or antihypertensive). o Drug indication:
- Considered the therapeutic uses and effects of drugs – addresses why we administer a specific drug.
- Understanding the desired outcome of administering a drug is an important part of nursing responsibilities related to medication administration. o Mechanisms of drug action:
- Pharmacokinetics is the effect the body has on a drug once the drug enters the body – it is the movement of drug molecules in the body in relation to the drugs absorption, distribution, metabolism, and excretion. Absorption: the process by which a drug is transferred from its site of entry into the body to the bloodstream – absorption of a drug is influenced by the following factors: o Route of administration o Lipid solubility o pH o Blood flow o Local conditions at the site of administration o Drug dosage Distribution: occurs after a drug has been injected or absorbed into the bloodstream – the molecules are transported throughout the body to where they take action. o Distribution depends on: (1) the adequacy of blood circulation; (2) protein binding, which affects drug’s ability to leave the bloodstream or storage areas (such as muscle, fat, or other tissues) and enter cells; and (3) the selectively permeable blood-brain barrier that protects the CNS with its capillary wall,
returned to the liver and then eventually excreted by the kidney. o Adverse drug reactions (ADRs): harmful effects that lead to injury – they can be severe and may require discontinuation of the drug, depending on whether the benefit of the drug outweighs the harm from the adverse effect.
- Allergic effect
- Drug tolerance
- Toxic effect
- Idiosyncratic effect
- Drug interactions Additive effect: drugs with similar pharmacologic actions; results in an increase in the overall effect. Synergistic effect: drugs with different sites or MOA; results in greater effects when taken together (one drug potentiates the other). Antagonistic effect: combined drugs alter the overall sum effect or negate each other; results in an effect less than that of each drug alone. Interference: one drug interferes with the metabolism of another; leads to the buildup of medication (that cannot be metabolized) and can result in toxicity or an ADR. Displacement: one drug binds to protein-binding sites and forces another drug to be displaced; results in the released drug becoming pharmacologically active and can lead to an increase in the effect of the unbound drug. o Side effects: mild, predictable, and may be tolerated as part of the therapy. o Factors affecting drug action:
- Developmental considerations
- Weight
- Biological sex
- Cultural and genetic factors
- Psychological factors
- Pathology
- Environment
- Timing of administration o Drug blood level monitoring: goal is to maintain a therapeutic level of a drug in the body.
- Develop an understanding of basic principles of pharmacology, including mechanisms of drug action, adverse drug reactions, and factors affecting drug action. SEE PAGES 823-830 !!!
- Discuss principles of medication administration, including an understanding of medication orders, dosage calculations, and medication safety measures. Prescription and order both refer to the means by which a provider communicated information regarding medications (and other procedures and therapies) to the health care team. o Medication orders:
- There are several types of orders that a prescriber may write. A routine order or standing order: is carried out as specified until it is canceled by another order or the prescriber specifies that a certain order it to be carried out for a stated number of days or times – after the stated period has passed, the order is discontinued automatically. PRN order (as needed): patient receives medication when it is requested or required, and when the specifics of the order are met.
