Week 10

Question 1

Data forms or assessment forms

Answer 1

Details
Assist with identifying problem areas

Question 2

Home assessment forms

Answer 2

Changes that need to be made to clients home

Question 3

Care plan

Answer 3

Contains goals and interventions

Question 4

Other flow sheet

Answer 4

Record measurement and observations

Question 5

Summary report

Answer 5

Monthly or every so often summary of clients condition/services used

Question 6

Progress report (RN) or narrative note (PSW)

Answer 6

Care that we provided

Question 7

Graphic sheets

Answer 7

Record measurement and observations

Question 8

ADL checklist and flow sheets

Answer 8

Sometimes called risk sheets

Question 9

Task sheets

Answer 9

Record provided care and services

Question 10

Incident report

Answer 10

Written account made after accident, error or unexpected event

Question 11

Kardex

Answer 11

One - two page document that is updated frequently

Question 12

Agency polices about medical records address:

Answer 12

Who records, when records
Terminology, abbreviation, correcting errors

Question 13

What to do for an error

Answer 13

Cross a line through it,
Write mistake and why,
Date, name, signature

Question 14

SOAP

Answer 14

Subjective data
Objective data
Assessment
Plan

Question 15

PIE

Answer 15

Problem
Intervention
Evaluation

Question 16

ADPIE

Answer 16

Analysis
Diagnosis
Problem
Intervention
Evaluation

Question 17

DAR charting

Answer 17

Data
Analysis and action
Response

Question 18

Transfer of accountability (TOA)

Answer 18

Handover of information between shifts
Sometimes recorded, written, or vocal
Formal process
Objective, appropriate, and concise
Writte up patient observations

Question 19

TOA tips

Answer 19

Be organized
Stay focus
Stay relevant
Communication clearly
Be patient- centred
Allow time

Question 20

ISBAR

Answer 20

Identify
Situation
Background
Assessment
Recommendation