DOCUMENTING

Question 1

an informal oral consideration of a subject by two or more health care personnel to identify a problem

Answer 1

DISCUSSION

Question 2

Is oral, written, or computer-based communication intended to convey information to others

Answer 2

REPORT

Question 3

only a written/computer based

Answer 3

RECORD

Question 4

recording is also called

Answer 4

charting or documenting

Question 5

is the process of making an entry on a client record

Answer 5

RECORDING

Question 6

clinical record is also called

Answer 6

chart/client record

Question 7

It is a formal, legal document that provides evidence of a client’s care

Answer 7

CLINICAL RECORD

Question 8

The nurse has a duty to maintain _____ of all patient information”

Answer 8

confidentiality

Question 9

Access to the record is ____ to health professionals involved in giving care to the client

Answer 9

restricted

Question 10

who is the rightful owner of the client’s record

Answer 10

The institution or agency

Question 11

purpose of client records

Answer 11

Communication
Planning client care
Auditing Health Agencies
Research
Education
Reimbursement
Legal Documentation
Health Care Analysis

Question 12

the traditional client record each person or department makes notations in a separate section/s of the client’s record

Answer 12

SOURCE-ORIENTED RECORD

Question 13

example of source oriented record

Answer 13

the admission dept. – Admission sheet

the physician – Doctor’s order sheet

A physician’s history sheet

Progress notes

Question 14

the traditional part of the source-oriented record

Answer 14

Narrative Charting

Question 15

It consists of written notes that include routine care,
normal findings, and
client problems.

Answer 15

Narrative Charting

Question 16

meaning of POMR

Answer 16

PROBLEM-ORIENTED MEDICAL RECORD

Question 17

who established POMR

Answer 17

Lawrence Weed

Question 18

what record in which the data arranged according to the problems the client has rather than the source of the information

Answer 18

POMR

Question 19

4 COMPONENTS OF POMR

Answer 19

Database

Problem List

Plan of Care

Progress Notes

Question 20

FORMATS OF PROGRESS NOTES

Answer 20

SOAP, SOAPIE/SOAPIER ; PIE

Question 21

meaning of SOAP

Answer 21

subjective
objective
analysis
planning

Question 22

SOAPIE/SOAPIER means what

Answer 22

subjective
objective
analysis
planning
intervention
evaluation
revision

Question 23

meaning of PIE

Answer 23

problem
intervention
evaluation

Question 24

consists of all information known about the client when the client first enters the health Care agency

Answer 24

Database

Question 25

problems are listed in the order in which they are identified, and the list is continually updated as new problems are identified and others are resolved

Answer 25

Problem List

Question 26

the initial list of orders made with reference to the active problems.

Answer 26

Plan of Care

Question 27

advantage sa pomr

Answer 27

encourage collaboration alerts caregivers to clients needs; easier to track problems

Question 28

disadvantages of pomr

Answer 28

caregivers ability to use charting format takes constant vigilance to maintane an up to date list inefficient (assessments & interventions are repeated)

Question 29

is intended to make the client and client concerns and strengths the focus of care.

Answer 29

FOCUS CHARTING

Question 30

recrding in focus charting consist of

Answer 30

date and time focus progress notes

Question 31

which charting utilizes DAR

Answer 31

focus charting

Question 32

meaning of DAR

Answer 32

data, action and response

Question 33

a documentation system in which only abnormal or significant findings or exceptions to norms are recorded.

Answer 33

CHARTING BY EXCEPTION

Question 34

3 elements of charting by exception

Answer 34

flow sheets standard of nursing care bedside access to chart forms

Question 35

like graphic record, fluid balance record, daily nursing assessment record, client teaching record, client discharge record and skin assessment record

Answer 35

Flow sheets

Question 36

are being developed as a way to manage the huge volume of information required in contemporary health care

Answer 36

COMPUTERIZED DOCUMENTATION

Question 37

emphasizes quality, cost-effective care delivered within an established length of stay

Answer 37

CASE MANAGEMENT

Question 38

Uses a multidisciplinary approach to planning and documenting client care, using critical pathways.

Answer 38

CASE MANAGEMENT

Question 39

DOCUMENTING NURSING ACTIVITIES:

Answer 39

1. Admission Nursing Assessment 2. Nursing Care Plans 3. Kardexes 4. Flow Sheets 5. Progress Notes

Question 40

also referred to as an initial database, nursing history, or nursing assessment, is completed when the client is admitted to the nursing unit

Answer 40

Admission Nursing Assessment

Question 41

2 TYPES OF NURSING CARE PLANS

Answer 41

traditional standardized

Question 42

a care plan that is written for each client. Mostly, it has 3 columns: nsg. diagnosis, expected outcomes, and nsg. interventions

Answer 42

traditional

Question 43

care plan that was developed to save documentation time.

Answer 43

standardized

Question 44

a widely used, concise method of organizing and recording data about a client ;consists of a series of cards kept in a portable index file or on a computer-generated forms.

Answer 44

Kardexes

Question 45

made by nurses to provide information about the progress a client is making toward achieving desired outcomes.

Answer 45

Progress Notes

Question 46

GENERAL GUIDELINES FOR RECORDING

Answer 46

Date and Time Timing Legibility Permanence Accepted Terminology Correct Spelling Signature Accuracy Sequence Appropriateness Completeness Conciseness Legal prudence

Question 47

purpose of reporting

Answer 47

to communicate specific information to a person or group of people

Question 48

is given to all nurses on the next shift. Its purpose is to provide continuity of care

Answer 48

Change-of-Shift Reports

Question 49

reports done through telephone

Answer 49

Telephone Reports

Question 50

orders made by physicians through telephone. Transcribed onto the physician’s order sheet and should be counter signed within 24 hours by the physician who made the order

Answer 50

Telephone Orders

Question 51

is a meeting of a group of nurses to discuss possible solutions to certain problems of a client.

Answer 51

Care Plan Conference

Question 52

are procedures in which two or more nurses visit selected clients at each client’s bedside.

Answer 52

Nursing Rounds