NURSING I - FON Ch 26 Documentation & Informatics

Question 0

Nurses are responsible for protecting records form ___.

Answer 0

all unauthorized readers.

Question 1

Anything written or printed on which you rely as record or proof of patient actions & activites

Answer 1

Documentation

Question 2

HIPPA requires that (1) __ or requests regarding health info are ____.

Answer 2

1. disclosure

2. limited to the minimum necessary.

Question 3

Standards: Current documentation standards require that each patient have an ___.

Answer 3

an ASSESSMENT (you have 24 hrs)

Question 4

Documentation Standards: All assessments to be included (7)

Answer 4

Physical
Psychosocial
Environmental
Self-Care
Patient Education
Knowledge Level
Discharge & Planning needs

Question 5

DON’T FORGET!

Patient’s Record or Chart / Documentation is (3):

Answer 5

1. Confidential
2. Permanent
3. Legal (can be used in the court of law)

Question 6

Limiting nursing LIABILITY:

Documentation must indicate that a patient received (1) __, (2) ___ nursing care based on the (3) __ __.

Answer 6

1. individualized
2. goal-directed
3. nursing assessment

Question 7

Common charting mistakes (6): Failure to record…

Answer 7

1. pertinent health or drug info
2. nursing actions
3. that medications have been given
4. drug reactions or changes in conditions
5. legibly or complete records
6. discontinued medications

Question 8

Purposes of Records (6):

Answer 8

1. Communication
2. Legal documentation
3. Reimbursement (billing)
4. Education
5. Research
6. Auditing / Monitoring

Question 9

The patient’s record communicates patient (5):

Answer 9

1. NEEDS and PROGRESS
2. individual THERAPIES
3. content of CONSULTATIONS
4. EDUCATION
5. DISCHARGE planning

Question 10

DRGs

Answer 10

Diagnosis-related Groups

Question 11

Basis for establishing reimbursement for patient care

Answer 11

DRGs

Question 12

Legal Guidelines for Recording

Answer 12

1. Correct all errors promptly (correct method)
2. Record all facts
3. No blank spaces
4. Legibly in black ink
5. Records if clarification was sought
6. Chart for SELF only
7. Avoid generalizations
8. Date/Time, Signature, Title
9. Secure passwords

Question 13

SPN

Answer 13

Student Practical Nurse

Question 14

Methods of Recording (8):

Answer 14

1. Paper Record
2. Electronic Health Record (EHR)
3. Narrative
4. Problem-oriented Medical Record (POMR)
5. SOAP
6. SOAPIE
7. PIE
8. Focus Charting (DAR)

Question 15

Paper & Electronic Health Records are __ -oriented.

Answer 15

episode

Question 16

Traditional method for recording nursing care.

The use of a story-like format.

Answer 16

Narrative Documentation

Question 17

Method of documentation that emphasizes patients’ problems.

Each member of Team contributes to a single list of identified patient problems = coordinates common plan of care.

Answer 17

Problem-oriented Medical Record (POMR)

Question 18

POMR: Data is organized by __ or __.

Answer 18

problem

diagnosis

Question 19

SOAP

Answer 19

Subjective
Objective
Assessment
Plan

Question 20

PIE

Answer 20

Problem
Intervention
Evaluation

Question 21

Focus Charting (DAR)

Answer 21

See page 354

Question 22

(Definition)

Answer 22

Source record

Question 23

(definition)

Answer 23

Charting by Exception (CBE)

Question 24

The assumption with CBE is that all standards are met, unless __ __.

Answer 24

otherwise documented

Question 25

(definition)

Answer 25

case management

Question 26

(definition)

Answer 26

critical pathways

Question 27

(definition)

Answer 27

variances

Question 28

(definition)

Answer 28

health informatics

Question 29

(define, explain)

Answer 29

SBAR

Question 30

(definition)

Answer 30

flow sheets

Question 31

(definition)

Answer 31

Kardex

Question 32

(definition)

Answer 32

standardized care plans

Question 33

Common Record-Keeping Forms

Answer 33

1. Admission Nursing History Form
2. Flow Sheets
3. Kardex
4. Standardized Care Plans
5. Discharge Summary Forms
6. Acuity Records

Question 34

Hand-Off Report

Answer 34

(page 358)

Question 35

Guidelines for Telephone and Verbal Orders

Answer 35

(page 358)