Health Assessment, Documentation & EHR

Question 1

engorged, distended jugular veins reflecting increased venous pressure in the right side of the heart which, in turn, indicates an increased central venous pressure

Answer 1

Jugular Venous Distention

Question 2

high-pitched sounds heard over the trachea with expiration longer than inspiration

Answer 2

Bronchial Breath Sounds

Question 3

medium-pitched blowing sounds heard over the main stem bronchus with expiration equal to inspiration

Answer 3

Bronchovesicular Breath Sounds

Question 4

closure of mitral & tricuspid valves

Answer 4

S1 Heart Sound (Normal)

Question 5

closure of aortic & pulmonic valves

Answer 5

S2 Heart Sound (Normal)

Question 6

ventricular gallop- impending heart failure

Answer 6

S3 Heart Sound (Abnormal)

Question 7

atrial gallop

Answer 7

S4 Heart Sound (Abnormal)

Question 8

turbulent blood flow through heart

Answer 8

Murmur

Question 9

PQRST Pain Assessment

Answer 9

What PROVOKES the pain? What is the QUALITY of the pain? Does it RADIATE? What is the SEVERITY of the pain? What is the TIMING of the pain?

Question 10

method of delivering care using an interdisciplinary approach to document patient care and focusing on providing quality care in a cost-effective manner

Answer 10

Case Management Plan

Question 11

charting using a narrative format that places less emphasis on patient problems and focuses on patient concerns such as signs & symptoms, conditions, behaviors or significant event

Answer 11

Focus Charting

Question 12

similar to SOAP charting in its problem-oriented nature having a nursing origin

Answer 12

Problem, Intervention, Evaluation (PIE) Charting

Question 13

structured method of documentation that emphasizes the patient’s problems

Answer 13

Problem-Oriented Medical Record (POMR)

Question 14

method of charting using subjective data, objective data, assessment & plan

Answer 14

SOAP Charting

Question 15

innovative approach to reduce the time required to complete documentation; agency defines criteria for nursing assessments and standards of practice for nursing interventions

Answer 15

Charting By Exception (CBE)

Question 16

flip-over card file kept at nursing station providing information for the daily care of a patient

Answer 16

Kardex

Question 17

part of the permanent health record and allow documentation of certain routine observations or specific measurements made repeatedly such as height & weight, ADLs

Answer 17

Flow Sheet or Graphic Records

Question 18

reporting method using situation, background, assessment, and recommendation

Answer 18

SBAR reporting

Question 19

the most common type of record where the patient chart is separated into sections that contain forms for each discipline

Answer 19

Source-Oriented Charting (SO)

Question 20

science and art of turning data into information

Answer 20

Informatics

Question 21

a nursing specialty that manages & communicates data, information, knowledge & wisdom by integrating nursing computer and information science

Answer 21

Nursing Informatics

Question 22

A federal group formed in 2005 to advise the Secretary of the Department of Health and Human Services on methods of increasing EHR adoption in healthcare facilities.

Answer 22

American Health Information Community (AHIC)

Question 23

a set of standards, services and policies that enable secure health information exchange (HIE) over the Internet.

Answer 23

National Health Information Network (NHIN)

Question 24

an initiative that enables clinicians to use informatics and emerging technologies to make healthcare safer, more effective, efficient, patient-centered, timely and equitable by interweaving evidence and technology seamlessly into practice, education and research fostering a learning healthcare system.

Answer 24

Technology Guiding Informatics Education Reform (TIGER)