Charting 2

Question 1

narrative method of charting

Answer 1

the traditional method

Question 2

problem-oriented medical record (POMR)

Answer 2

database, problem limit, nursing care plan, progress note

Question 3

SOAP

Answer 3

subjective, objective, assessment, plan

Question 4

SOAPIE

Answer 4

subjective, objective, assessment, plan, intervention, evaluation

Question 5

PIE

Answer 5

problem, intervention, evaluation

Question 6

Focus Charting (DAR)

Answer 6

Data, Action, Response

Question 7

source records

Answer 7

a separate section for each discipline (what the hard chart is now)

Question 8

charting by exception (CBE)

Answer 8

focuses on documenting deviations (when compromised chart)

Question 9

case management plan and critical pathways

Answer 9

incorporates a multidisciplinary approach to care

Question 10

WNL

Answer 10

everything by case definition was met

Question 11

common record keeping forms

Answer 11

admission nursing home history form, flow sheets and graphic records, client care summary or Kardex (SBAR), acuity records, standardized care plans, discharge summary form

Question 12

medicare has specific guidelines for

Answer 12

establishing eligibility for home care (home care documentation)

Question 13

documentation is the quality control and justification for reimbursement from

Answer 13

medicare, medicaid, or private insurance (home care documentation)

Question 14

nurses need to document all their services for

Answer 14

payment OASIS (home care documentation)

Question 15

governmental agencies are instrumental in determining the

Answer 15

standards and policies for documentation (long-term health care documentation)

Question 16

the Omnibus Budget Reconciliation Act of 1987

Answer 16

includes Medicare and Medicaid legislation for long-term health care documentation

Question 17

the department of health in states governs the

Answer 17

frequency of written nursing records (long-term health care documentation)

Question 18

never talk about what type of report in the chart

Answer 18

incident reports

Question 19

what do you always have to read back

Answer 19

verbal or telephone orders

Question 20

how to document verbal/telephone order

Answer 20

Doctor Name Rachael Garland TORB (doctor has to sign within 24 hours)

Question 21

reporting

Answer 21

change of shift, telephone reports, verbal/telephone orders, transfer reports, incident reports

Question 22

software programs allow nurses to

Answer 22

enter assessment data

Question 23

computers generate

Answer 23

nursing care plans and document care

Question 24

HIPPA

Answer 24

started in 2003, app to give patient greater control over their own records