68WM6 Documentation Word Scramble
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Question | Answer |
Routine care | Chief complaint; subjective and objective findings; diagnosis; treatment plan; response to treatment. |
Condition change | Professionals have an obligation to recognize condition change and take action. Can only illustrate this through documentation. |
The chart is used as a | utilization record |
Factual, Objective Notations are | What you hear, see, feel, and smell. |
Tampering | You may be asked whether or not you tampered with the record when the record is requested. |
A lawyer may ask you this in regards to editing a nursing document in court..... | More likely it is, “Did you alter the record in any way?.” This is much broader. |
Drug doses | Units vs. a zero (always write out units). |
Why use leading zero for decimals? | (ensures decimal is recognized). |
If it is documented, it is assumed to be | accurate |
Is it okay to document ahead of time? | Never document ahead |
Grammar and cleanliness are worthwhile: messy notes give an appearance of | messy care. |
When a patient does not cooperate with medical care what can we do in the patient chart? | Use quotes when possible to illustrate the non-compliant behavior. |
If a patient wants to leave against medical advice what should you do? | Document every detail and advise the patient of the consequences. If possible, try to get patient to sign refusal of care document. |
An LVN can only execute what kind of orders? | Written orders |
Telephone and Verbal orders can only be taken by whom? | RN's |
Medication orders must include | Medication name.Dose.Route.Frequency. |
Assessment | a systematic and continuous collection, and communication of pt data |
Diagnosis | an analysis of pt data to identify patient strengths and health problems identified which independent nursing interventions can prevent or resolve. |
Planning | the establishment of pt goals to prevent, reduce, or resolve the problems identified in the nursing diagnoses. The nsg dx guides the development pertinent nsg interventions. |
Implementation | putting into practice the plan of care |
Evaluation | measurement of the extent to which the patient has achieved the goals specified in the plan of care. |
Comprehensive Assesment (Complete): | provides baseline patient information which includes Physical examination of all body systems. Appropriate for stable patients. |
concentration of attention on the part of the body where signs and symptoms are localized or most active in order to determine their significance. | Focused |
Focused assesments are appropriate for... | critically ill, disoriented, or unable to respond patients. |
Ongoing Assesment | systematic follow-up is required when problems are identified during a comprehensive or focused assessment. |
Subjective Information | verbal statements from the patient. |
Objective | observable and measurable which can be recorded. |
Primary Source of Information | patient. Collected from patient interview and physical examination. |
Secondary Source of Information | family members, significant others, health care team, medical records, diagnostic procedures, and nursing literature. |
Data clustering | process of putting data together in order to identify areas of the patient's problems and strengths. Mixing all your data together like a tasty martini |
Hierarchy of needs (Maslow's) | individual's basic needs must be meet before higher-level needs can be met. |
Actual Nursing Diagnosis | a condition that is currently present. |
Risk | is a clinical judgement that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation. |
Possible | when a problem is considered feasible. |
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