Documentation

Question 1

Healthcare workers spend ____% of time documenting

Answer 1

40 %

Question 2

Reduces errors, built in clinical alerts are all factors of __?

Answer 2

Electronic health records

Question 3

When a nurse documents clients finding using flow sheet and only document unusual findings. For “normal” findings they document “WDL”.
This is an example of ?

Answer 3

Charting by exception

Question 4

Progress notes are useful for ?

Answer 4

Clarification and follow up on unusual findings

Question 5

Provider, PT, OT, RT, progress notes are important to read in order to ?

Answer 5

Help with collaboration, apprise to patients plan of care

Question 6

______ allows providers to document findings in an organized manner.

Answer 6

SOAP

Question 7

S in SOAP stands for?

Answer 7

Subjective

Question 8

O in SOAP stands for ?

Answer 8

Objective

Question 9

A in SOAP stands for?

Answer 9

Assessment

Question 10

P in SOAP stands for ?

Answer 10

Plan

Question 11

What elements of the nursing process are missing in SOAP?

Answer 11

Intervention and evaluation

Question 12

Another way to document findings in an organized manner is through ____

Answer 12

PIE

Question 13

The P in PIE stands for ?

Answer 13

Problem

Question 14

The I in PIE stands for ?

Answer 14

Intervention

Question 15

The E in PIE stand for ?

Answer 15

Evaluation

Question 16

When computers go down and you must use paper charting this is called?

Answer 16

Downtime charting

Question 17

The guidelines for sound documentation are based on what acronym?

Answer 17

FACT

Question 18

F in FACT stands for?

Answer 18

Factual
Concrete objective findings
Subjective findings in “quotations”

Question 19

A in FACT stands for ?

Answer 19

Accurate
Use exact measurements

Question 20

C in FACT stands for?

Answer 20

Complete
Do not leave out important information

Question 21

T in FACT stands for?

Answer 21

Timely
Document after providing care

Question 22

When are verbal orders used?

Answer 22

Only in emergency situations

Question 23

When getting a telephone order you must confirm?

Answer 23

Patients ID, allergies & have patients chart available

Question 24

In telephone orders each medication ordered must contain which information?

Answer 24

Name, dose, strength, route, time/frequency, indication, special instructions

Question 25

True or False
Record prescription in patient’s chart while taking order

Answer 25

True