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Found of Nursin Ch.7
Documentation
Question | Answer |
---|---|
The person who is appointed to examine patients charts and health records to assess quality of care is known as ______________. | Auditors |
The ___________is a system used to consolidate patient orders and care needs in a centralized, concise way. | Kardex (or Rand). |
The five basic purposes of written patient records are: | 1) Written Communication 2) Permanent record for accountability 3) Legal Record of Care 4) Teaching 5) Research and Data Collection |
How does home health care documentation relate to reimbursement? | Documentation provides the justification for reimbursement because nurses have to document all of their services for payment (e.g., direct skilled care, patient instructions, skilled observations, and evaluation visits). |
A system that is used by medicare for reimbursement of patient care services is ____. | Diagnosis-related group. |
The most accurate definition of the patient's chart is : | A legal record used to meet the many demands of the health system. |
What is the purpose of an incident report? | A record of any event that is not consistent with the routine operation of a health care unit or the routine care of a patient. THIS INFORMATION HELPS THE FACILITY RISH MANAGER AND UNIT MANAGERS PREVENT FUTURE PROBLEMS THROUGH EDUCATION AND OTHER MEASURES |
An incident report is included as part of a person's medical record. True or False | False. |
What is the relationship between Kardex and the patient's chart? | The Kardex contains cumulative information based on the information required for care from the patients chart in a quick reference format at the nurse's station. |
What are the advantages of computer documentation? | 1. eliminate repetitive entries 2. freedom to access the database. 3. Allows for quick interaction between various departments (lab, dr, pharmacy, billing, etc. 4. Easy to transfer as it is electronic. |
What are the disadvantages of computer documentation? | 1. programs need to be kept up to date with systems. 2. Training of personnel can take some time. 3. May use a unique language for that specific agency on that computer system. 4. Possible confidentiality concerns. |
Focus charting contains ___________ and ___________. | Nursing action and patient response. |
Charting by exception: | decreases the time needed to complete the nurse's notes. |
What type of charting format usually requires the most time to complete? | Narrative |
What type of charting format most reflects the nursing process? | Focus |
What documentation is included in the "P" when using the PIE method of charting? | Problem List |
The POMR is divided into which four major sections? | Database, problem list, (care) plan, and progress notes. |
The problem oriented medical record does what? | It uses a patient problem list as an index for chart documentation. |
The charting format most commonly used for documentation of clinical pathways is _______________. | Charting by Exception (CBE). |
What are the basic guidelines for charting? | Correct spelling, punctuation, and grammar. Good penmanship Information is clear, concise, and accurate. |
Confidentiality of a patient's medical record is guaranteed by? | HIPAA |
Who owns a medical record/Health Care Record? | Institution or Physician |
Patients have immediate access to their medical record. True or False | False. The only exception is VA hospitals. |
What happens when an error is made by the nurse in charting? | A line is drawn through the error and initialed, and then the nurse continues with the charting. |
Confidentiality is most often maintained with use of computer charting through the: | assignment of individual passwords |
Inadequate documentation that is commonly involved in cases of malpractice includes: | 1. documenting incorrect data 2. charting nursing actions in advance 3. charting incorrect times at which events occurred. 4. failing to record verbal orders or failing to havbe them signed. |
When documenting care and observations in a patient record: | Use of approved medical terms and abbreviations are permitted. |
patient healt care records are: | concise, legal records of all care given and responses. |
When the POMR method is used for documentation: | the charting format is SOAPE or SOAPIER |
The nurse is usint the SOAPE method to chart. In this method the S stands for | subjective information the patient states or feels. |
When charting the nurse should | chart as soon and as often as necessary. |
Understanding that health care personnel must respect the confidentiality of patients records, the nurse should: | read charts only for a professional reason. |
The use of computers in the hospital by nurses: | can save on charting time once nurses are comfortable using computers. |
When completing and incident report, the nurse is aware that it is necessary to: | Document facts regarding the incident. |
Charting by exception documents those conditions, interventions, or outcomes outside the norm. True or False | True |
What is a recommended guideline for charting? | Have the patient names and identification number on every sheet. |
The 24-hour patient care record-keeping system is useful in | consolidating the nursing record. |
Acuity charting requires what? | Staff to document their interventions. |
Which accredidation agency specifies guidelines for documentation? | The Joint Commission (TJC) |
When comparing documentation for acute care in hospitals with documentation for long-term care, majore diferences are related to : | The prospective payment system determing the standards for reimbursement. |
What kind of documentation method describes occurences in chronological order? | Narrative documentation |
Standards and policies regarding documentation in long-term care facilities is guided by _______. | MDS |
The government reimburses agencies for health care costs incurred by Medicare and medicaid recipients based on ____________. | Diagnosis-related groups. |
Auditors | people apointed to examine a patients charts and health records to assess quality of care. |
Chart (Health Care Record) | Legal record that is used to meet many demands of the health accrfedidation, medical insurance, and legal systems. |
Charting | Process of recording information on a patients chart. |
Chart by Exception (CBE) | Recording only new data or changes in a patient status or care. |
Database | Large store or bank of information. |
Diagnosis Related Group (DRG) | System that classifies patients by age, diagnoses, and surgical categories. |
Documenting | Process of adding information to the chart, usually at prescribed intervals. |
Kardex (or RAND) | Card system used to consolidate patient orders and care needs in a centralized, concise way. |
Narrative Charting | Nurse documents in story form all pertinent patient observations, care, and responses. |
Nomenclature | A classified system of technical or scientific names and terminology. |
Nursing Care Plan | Plan care based on Nursing assesment and nursing diagnosis |
Nursing notes | Form on the patients chart on which nurses record their observations, care given, and the patients responses. |
Peer Review | an appraisa by professional co-workers of equal status. |
Problem List | Prioritized master list of the patients active, inactive, temporary, and at-rishk medical or other problems. |
Problem-Oriented Medical Record (POMR) | Method of recording data about the health status of a patient in a problem-solving system. |
Quality Assurance, Assesment, and improvement | An evaluation of services provided ana the results acheives as compared with accepted standards. |
Recording | Process of adding written information to the chart, usually at prescribed intervals. |
SOAPIER | USED IN POMR charting S - subjective O - Objective A - Assesment P - Plan I - Intervention E - Evaluation R - Revision |
Traditional (block) chart | Traditional chart broken down into sections or blocks. |