Which of the following assessment findings would be documented as objective data
In the article Nursing record systems: effects on nursing practice and healthcare outcomes by Urquhart C, Currell R, Grant MJ, Hardiker NR nurses document to record the care that was planned, any deviations, and the actual care given to each patient by the registered nurse (RN) or any caregivers working with the RN to provide patient care. The article further states that documentation should demonstrate the legality of the care given and should be professionally completed. Legally only actions or care documented are seen as being completed. This sentiment is reflected by the nurse’s mantra of “If it was not documented, it was not done.” It is important that these rules apply to written documentation in the physical chart and electronic charting (EHR). Other aspects of documentation include the importance of documenting in a timely manner, avoiding using abbreviations, and writing the note in grammar-appropriate standard English. Remember, if the note goes to court it is important that the jury can read it grammatically and legibly. Show
Documentation is used for:
The primary care provider (MD, NP, PA), consulting physicians, social worker, Physical therapist, occupational therapist, nutritionist, and possibly the clinical pharmacist all use the progress note section to document. Nurses use the “Nurse’s Notes” or the progress note section to communicate therefore, it is important that the nurse read the physical or electronic progress note to determine the patient’s course of care and possible discharge dates. Seven criteria for nursing documentation were presented in 2010 by Jefferies, Johnson, and Griffiths (2010:119) in the paper: “A meta-study of the essentials of quality nursing documentation.” The seven criteria for professional and legal documentation include Patient-centered, contain the nursing care given, reflect the nurses’ clinical judgment, is presented in a logical order, written in real-time, document variance in the patient’s care, and fulfill the legal requirements. The nurse needs to document significant events and information in any patient’s ongoing care from assessment, planning, intervention, and evaluation. Documentation facilitates safety and quality care in so many ways, one of which is the continuity of care from one practitioner to the other. There are also ethical, legal, and financial implications of correct and accurate documentation. Lastly, the literature indicates that nursing documentation can be an indicator of quality nursing practice and patient mortality. All types of documentation must have the date, time, and signature of the person documenting. II. When does the nurse document?
III. The nurse may use different types of documentation.The type used is normally mandated by the hospital and may be different in the critical care areas of the Emergency Department, the Intensive Care Units, Hemodialysis and Psychology. The most commonly used types are listed here:
The third type of note is the Narrative note:
The fourth type of note is the SOAPIE:
The fifth type of note is the Patient Discharge Summary:
https://youtu.be/J9SGNjrm2Ws The sixth type of documentation is the Minimum Data set (MDS) Charting Minimum Data Set (MDS) Charting In long-term care settings, additional documentation is used to provide information for reimbursement by private insurance, Medicare, and Medicaid. The Resident Assessment Instrument Minimum Data Set (MDS) is a federally mandated assessment tool created by registered nurses in skilled nursing facilities to track a patient’s goal achievement, as well as to coordinate the efforts of the health care team to optimize the resident’s quality of care and quality of life. This tool also guides nursing care plan development. The link above gives a great review of what was discussed above, more samples of narrative documentation, samples of documentation flow sheets, and discusses documentation and the state law (Texas). Please remember that each state has a Nursing Board of Licensure which maintains a state-specific Nursing Practice Act. V. The most commonly used type of documentation used now is electronic documentation.The same rules apply but the medium has changed from paper to computer: In today’s health care environment, all the information in the prior guide must also be applied to electronic health records management. The following video by the Oncology Nursing Society discusses the value of electronic health records: The EHR for each patient contains a great deal of information. The most frequent pieces of information that nurses access include the following:
VI. A sample of an electronic health record (EHR) Physical Assessment Document Here is a sample of an Electronic Health Record of a Physical Assessment A more detailed overview of what and how to document. Please click the link below: Do-s-and-Don-ts-of-Documentation-Infographic_V6 VI: Learning Activity:VI. Citations and AttributionsUrquhart C, Currell R, Grant MJ, Hardiker NR. Nursing record systems: effects on nursing practice and healthcare outcomes. Cochrane Data Base Syst Rev. 2009;1:1–66. Tasew, H., Mariye, T. & Teklay, G. Nursing documentation practice and associated factors among nurses in public hospitals, Tigray, Ethiopia. BMC Res Notes 12, 612 (2019). https://doi.org/10.1186/s13104-019-4661-x 2.5 Documentation Open REsources for Nursing (open RN) by Wisconsin Technical College system Retrieved 13:35 July 27, 2021 https://wtcs.pressbooks.pub/nursingfundamentals/chapter/2-5-documentation/ OKAISU, Elisha M.; KALIKWANI, Florence; WANYANA, Grace and COETZEE, Minette. Improving the quality of nursing documentation: An action research project. Curationis [online]. 2014, vol.37, n.2 [cited 2021-07-27], pp.1-11. Available from:. ISSN 2223-6279. http://dx.doi.org/10.4102/curationis.v37i1.1251. Jefferies, D., Johnson, M. & Griffiths, R., 2010, ‘A meta-study of the essentials of quality nursing documentation’, International Journal of Nursing Practice 16, 112-124. http://dx.doi.org/10.1111/j.1440-172X.2009.01815.x [ Links ] KAISU, Elisha M.; KALIKWANI, Florence; WANYANA, Grace and COETZEE, Minette. Improving the quality of nursing documentation: An action research project. Curationis [online]. 2014, vol.37, n.2 [cited 2021-07-27], pp.1-11. Available from:. ISSN 2223-6279. http://dx.doi.org/10.4102/curationis.v37i1.1251. Discharge Teaching College & Association of Registered Nurses of Alberta uploaded May 21, 2019. Retrieved 17:30 July 27, 2021, https://youtu.be/J9SGNjrm2Ws Documentation by the Nurse-Texas Health and Human Services Commission Uploaded September 2016 Wikipedia, Retrieved July 25 2019 https://www.hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/provider-portal/QMP/NurseDocumentationPPT.pdf EHR Physical Assessment Document for Simulation – Includes Excel Template by Healthy Simulation Updated July 02, 2020, Retrieved 18:34 July 27, 2021 https://www.healthysimulation.com/14886/ehr-physical-assessment-document-for-simulation-includes-excel-template/ Which assessment findings are examples of objective data?Objective data is obtained during the physical examination component of the assessment process. Examples of objective data are vital signs, physical examination findings, and laboratory results.
What are objective assessment findings?Examples of objective assessment include observing a client's gait , physically feeling a lump on client's leg, listening to a client's heart, tapping on the body to elicit sounds, as well as collecting or reviewing laboratory and diagnostic tests such as blood tests, urine tests, X-ray etc.
What is objective data example?Objective Data
This is the information that we can gather using our 5 senses. It is either a measurement or an observation. Temperature is a perfect example of objective data. The temperature of a person can be gathered using a thermometer.
Which attributes are examples of objective data?Objective data is anything that you can observe through your senses of hearing, sight, smell, and touch while assessing the patient. Objective data is reproducible, meaning another person can easily obtain the same data. Examples of objective data are vital signs, physical examination findings, and laboratory results.
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