Documentation

Question 1

A collection of health info and data about and individual client’s health =

Answer 1

Health Record

Question 2

Type of documentation that omits the plan of care and utilizes flow sheets and progress notes =

Answer 2

PIE Model

Question 3

Traditional form of documentation, divided into specific sections within the medical record =

Answer 3

Source-Oriented Method

Question 4

Used to create a comprehensive + organized approach among all members of the interdisciplinary team =

Answer 4

Problem-Oriented Medical Record (POMR)

Question 5

SOAP Documentation =

Answer 5

Subjective
Objective
Assessment
Plan

Question 6

Centers on specific healthcare problems and the change in condition, client events and concerns. Three items must be documented which are data, action, and response (DAR).

Answer 6

Focus Charting

Question 7

PIE Model stands for-

Answer 7

Problems
Interventions
Evaluations

Question 8

Acronym used to help nurses with proper documentation practices.

Answer 8

FACT

Question 9

FACT stands for-

Answer 9

Factual
Accurate
Complete
Timely

Question 10

PO

Answer 10

By Mouth

Question 11

Rx =

Answer 11

Prescription

Question 12

Stat =

Answer 12

At once

Question 13

HOB =

Answer 13

Head of bed

Question 14

BID =

Answer 14

Twice a day

Question 15

Verbal prescriptions =

Answer 15

Prescribed by provider directly

Question 16

Benefits of CPOE System?

Answer 16

Transcription errors are less likely
Medications can be administered faster

Question 17

CEB =

Answer 17

Charting by exception

Question 18

Charting by exception =

Answer 18

Only charting unexpected findings

Question 19

Emergency situations = what kind of prescription?

Answer 19

Telephone Prescription