Finals

Question 1

TYPES OF Clinical Documentation

Answer 1

-Medical History and Physical Examination
-Progress Notes
-Nursing Notes
-Physician Orders

Question 2

Patient’s past medical history, current conditions, and physical exam findings.

Answer 2

Medical History and Physical Examination

Question 3

Daily or periodic updates on a patient’s condition, treatment, and response to care

Answer 3

Progress Notes

Question 4

Documentation of patient care, assessments, and interventions by nurses

Answer 4

Nursing Notes

Question 5

Instructions from doctors regarding medications, treatments, or tests

Answer 5

Physician Orders

Question 6

Personal details, insurance information, and consent for treatment

Answer 6

Patient Registration Forms

Question 7

Documents signed by patients acknowledging risks and agreeing to procedures.

Answer 7

Informed Consent Forms

Question 8

Information related to medical billing, claims, and reimbursements

Answer 8

Insurance and Billing Records

Question 9

Records of any adverse events, errors, or accidents occurring in a healthcare facility

Answer 9

Incident Reports

Question 10

Legal documents specifying a patient’s healthcare preferences in case they cannot communicate

Answer 10

Advance Directives

Question 11

types of Administrative Documentation

Answer 11

-Patient Registration Forms
-Informed Consent Forms
-Insurance and Billing Records

Question 12

types of Legal and Compliance Documentation

Answer 12

-Incident Reports
-Advance Directives

Question 13

types of Specialized Documentation

Answer 13

-Laboratory Reports
-Radiology Reports
-Pharmacy Records
-Mental Health Records

Question 14

Results of blood tests, imaging, and other diagnostic studies

Answer 14

Laboratory Reports

Question 15

Interpretation of X-rays, CT scans, MRIs, etc

Answer 15

Radiology Reports

Question 16

Documentation of prescribed and dispensed medications

Answer 16

Pharmacy Records

Question 17

Psychological assessments, therapy notes, and treatment plans

Answer 17

Mental Health Records

Question 18

SMART documentation

what does SMART stand for

Answer 18

Specific
Measurable
Achievable
Relevant
Time-based

Question 19

key reasons why documentation is essential

list that

Answer 19

1. Ensures Quality Patient Care
2. Legal Protection & Accountability
3. Enhances Communication Among Healthcare Teams
4. Supports Billing and Insurance Claims
5. Improves Patient Safety & Reduces Errors
6. Facilitates Research, Education, and Public Health Monitoring
7. Supports Ethical and Professional Standards

Question 20

Ensures continuity of care when different providers or specialists are involved

Answer 20

Ensures Quality Patient Care

Question 21

Serves as legal evidence in case of malpractice claims or disputes

Answer 21

Legal Protection & Accountability

Question 22

Facilitates clear communication between doctors, nurses, and other healthcare professionals

Answer 22

Enhances Communication Among Healthcare Teams

Question 23

Provides proof of services for insurance claims and reimbursements

Answer 23

Supports Billing and Insurance Claims

Question 24

Prevents medication errors by documenting prescribed drugs and dosages

Answer 24

Improves Patient Safety & Reduces Errors

Question 25

Contributes to medical research by providing case studies and trends. Helps in disease surveillance and outbreak control

Answer 25

Facilitates Research, Education, and Public Health Monitoring

Question 26

Ensures ethical decision-making in patient care. Maintains patient confidentiality and professional integrity

Answer 26

Supports Ethical and Professional Standards

Question 27

the process of evaluating ethical dilemmas and choosing actions aligned with values, integrity, and justice

Answer 27

Moral decision-making

Question 28

refers to the ability to analyze ethical issues critically and make sound moral judgments

Answer 28

Moral discernment

Question 29

Principle of Moral Discernment list them

Answer 29

-Ethical Principle -Organizational policy -Legal and societal norms -Personal integrity and conscience

Question 30

refers to making ethical decisions based on a properly formed, educated, and morally guided conscience

Answer 30

Principle of Well-Informed Conscience

Question 31

Key Aspects of a Well-Informed Conscience

Answer 31

1. Knowledge & Awareness 2. Critical Thinking 3. Moral Principles 4. Ongoing Formation 5. Accountability & Responsibility

Question 32

Leaders must actively seek truth, facts, and ethical guidelines before making decisions

Answer 32

Knowledge & Awareness

Question 33

Ethical decisions require analysis, discernment, and rational judgment, avoiding bias or impulsive reactions

Answer 33

Critical Thinking

Question 34

A well-formed conscience aligns with justice, integrity, respect, and the common good

Answer 34

Moral Principles

Question 35

Continuous learning, ethical training, and reflection help leaders refine their moral decision-making

Answer 35

Ongoing Formation

Question 36

Ethical leaders take ownership of their choices, considering the impact on others and the organization

Answer 36

Accountability & Responsibility

Question 37

Recognize ethical dilemmas early. Identify stakeholders affected by the decision. Understand legal, moral, and organizational implications

Answer 37

Ethical Awareness & Problem Identification

Question 38

Choose the action that brings the greatest good for the most people

Answer 38

Utilitarian Approach

Question 39

Follow moral rules and duties regardless of consequences

Answer 39

Deontological (Duty-Based) Approach

Question 40

Act according to virtues like honesty, justice, and compassion

Answer 40

Virtue Ethics

Question 41

Ensure all parties are treated equitably

Answer 41

Justice & Fairness

Question 42

Consider the rights and choices of individuals

Answer 42

Respect for Autonomy

Question 43

Gather all relevant facts and perspectives. Consult laws, policies, and ethical guidelines. Differentiate facts from opinions

Answer 43

Critical Thinking & Data Collection

Question 44

Seek input from colleagues, ethics committees, or experts. Reflect on how the decision aligns with personal and organizational values

Answer 44

Stakeholder Consultation & Reflection

Question 45

Choose the most ethically justifiable action. Take responsibility for outcomes and consequences. Monitor the impact and adjust if necessary

Answer 45

Decision Implementation & Accountability

Question 46

Engage in ethics training and discussions. Analyze past decisions to improve future moral reasoning. Promote a culture of ethical leadership within the organization

Answer 46

Continuous Ethical Learning & Improvement

Question 47

Key aspects of service value include

Answer 47

Effectiveness Efficiency Equity Patient satisfaction

Question 48

This refers to how limited medical resources such as funding, staff, medications, and facilities are distributed across a healthcare system. Since no country has unlimited resources, decisions must be made about who gets what, and how much

Answer 48

Allocation of Health Resources

Question 49

Common Access Issues

Answer 49

-Geographic barriers -Financial barriers -Cultural/language barriers -System inefficiencies

Question 50

To strengthen the nursing profession in the Philippines by defining its scope, improving nursing education, regulating the practice, and protecting the rights and welfare of Filipino nurses

Answer 50

The Philippine Nursing Act of 2002 or Republic Act No. 9173

Question 51

what is Republic Act No. 9173

Answer 51

The Philippine Nursing Act of 2002