chap. 7-10

Question 1

what do we need to document

Answer 1

meds pt is on
anything out of the norm
adpie

Question 2

documentation shows as…

Answer 2

evidence that actions were taken and preformed

Question 3

documentation should be

Answer 3

concise, brief, straight to the point

done in blue or black inc

Question 4

charting used as…

Answer 4

audit tool by management

Question 5

what is charting by exception

Answer 5

only charting things outside the norm.

Question 6

patient can amend medical records?

Answer 6

true

Question 7

nursing relationship should be

Answer 7

honest, effective, empathy, nonjudgemental, accepting, respectful, and confidential

Question 8

when charting have

Answer 8

assessment, intervention, evaluation

Question 9

documentation process should be…

Answer 9

factual, current, complete, organized, and accurate

Question 10

accuracy in charting-

Answer 10

don’t use subjective words
be specific about size n amt
no assumptions

Question 11

factors affecting communication

Answer 11

cultural differences
past experiences
emotions n mood n environment
attitude of individual

Question 12

when communicatingwith the hearing impaired

Answer 12

speak distinctly
don't shout
speak slowly
get person's attention
use short sentences

Question 13

communication with aphasia or (can’t speak)

Answer 13

make environment relaxed n quiet
speak to pt as an adult
establish eye contact
ask 1 question at a time