Glisan Documentation Basics

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Timely, relevant and accurate documentation improves quality of care and resident outcomes. *

1 point

True

False

Some of the reasons good documentation matters are: (Select ALL correct answers) *

1 point

Higher quality care for residents, fewer “balls dropped”.

Be a team player-share information timely, clearly, accurately.

Give yourself credit for the care you provide.

In the eyes of regulators “if it isn’t documented, it didn’t happen.”

Protect yourself from allegations of abuse or neglect.

Protect yourself and your facility from lawsuits.

Job Security-it’s how the facility documents care for reimbursement (payment) and often determines staffing budgets.

Required

All Care Team Members have a contributing, active or supervisory role in documentation.

1 point

Yes

Someone reading the chart should be able to clearly understand what is happening with each resident and be able to continue providing safe and efficient care.
*

1 point

True

False

What should be documented? *

1 point

ALL care provided

Medications given or refused

Treatments completed or refused

Communication with providers, family, caseworkers etc.

Incidents

Changes in Resident Condition

Behaviors

Education Provided

Admission and Discharge Information

All of the above

None of the above

I should use the full date and time when I document. *

1 point

True

False

It is best to be clear and address one topic at a time when documenting. *

1 point

True

False

It is best to limit the use of abbreviations to ensure anyone reading the chart will have the same understanding and avoid confusion. *

1 point

True

False

The resident needs to be identified in every entry. *

1 point

True

False

Documentation should be concise and to the point. *

1 point

True

False

Documentation should be Objective, NOT Subjective. *

1 point

True

False

A subjective perspective is open to greater interpretation based on personal feeling, emotion, conjecture and assumptions, contain jargon, indicates bias, be critical, unnecessary information. It is an interpretation of what you feel, see, hear or think. *

1 point

True

False

An objective perspective is one that is not influenced by emotions, opinions, or personal feelings - it is a perspective based on fact, on things quantifiable, and measurable. What you see/feel/hear/smell (bleeding, Edema, Open skin)

1 point

True

False

This example is OBJECTIVE:

Claudia was crying and carrying on because Jackie had 'stolen' her jacket. Jackie had hidden the jacket behind her seat and was shouting and swearing telling everybody the jacket was hers. We gently took the weeping Claudia away and gave her a cookie. Later, at lunch time Jackie walked to the dining room forgetting the jacket on the chair. We then handed the jacket to Claudia and she was very happy. "

1 point

True

False

This example is SUBJECTIVE:

Myrna refused showers this morning. Care staff will reattempt to shower in the evening. Resident has a history of refusing showers due to her dementia. Notify supervisor if no showers x 3 days.

1 point

True

False

Correct grammar, punctuation and spelling make documentation easier to understand and more professional. *

1 point

True

False

If you don't think you can document perfectly it's better not to record anything. *

1 point

True

False

Documentation should be timely. *

1 point

True

False

Timely documentation can prevent errors in treatment

1 point

True

False

If I have some free time but I know I'll be busier later, it's okay to get ahead and document in advance. *

1 point

True

False

I should make my handwriting and signature legible. *

1 point

True

False

It isn't my responsibility to be familiar with my facility's policies. *

1 point

True

False

When I am unsure of how to do something I should look at the facility policies and procedures for guidance. *

1 point

True

False

If I make an error I should draw a single line through it, initial and date it. *

1 point

True

False

It's okay to use white out to correct documentation errors. *

1 point

True

False

It is best to use black or blue ink when handwriting on documentation. *

1 point

True

False

Progress notes are: *

1 point

an essential part of the documentation required in all types of care facilities.

record changes that impact on the delivery of care and used to review and update care/service plans.

provide an important means of communication among staff

are legal documents and should be accurate, plausible and clearly written

all of the above

none of the above

Changes in Condition should ALWAYS be documented. *

1 point

True

False

When making in incident note it is important to summarize what happened and what action was taken as a result to prevent recurrence. *

1 point

True

False

It is important to complete required assessments and evaluations in a timely manner, on schedule. *

1 point

True

False

Care Conferences should be documented. *

1 point

True

False

It is important for me to understand Alert Charting criteria and expectations. *

1 point

True

False

Not sure

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