Information and Documentation: 4 Questions Flashcards

1
Q

what is it where you “chart physiological data/routine care to see trends”?

A

Flow sheets

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2
Q

what documentation method is where it is “within normal limits unless documented otherwise (abnormal findings)”?

A

Charting by exception

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3
Q

what documentation method is where the “record progress toward resolving patient issues”?

A

progress notes

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4
Q

what documentation is where it is “comprehensive admission assessment”?

A

Admission Nursing History Form

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5
Q

what documentation is where it is “summary of care provided/used in shift reports”?

A

Patient Care Summary

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6
Q

what documentation is where it is “standardized care plans or clinical practice guidelines”?

A

care plans

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7
Q

what documentation is where it is “summary of discharge instructions/information”?

A

discharge summery forms

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8
Q

Failing to report nursing actions, pertinent or relevant health or dug information, medication administration, drug reactions or changes in person’s conditions, incomplete records, discontinued medications which can lead to what?

A

complications or malpractice

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