Question 1

Documentation

Accepted Answer

is the written or typed, legal record of all pertinent interactions with the patient- assessing, diagnosing, planning, implementing, and evaluating.

Question 2

Patient record

Accepted Answer

is a compilation of a patients health information. Patients record is the only permanent legal documentation that details the nurses interactions with the patient and is the nurses best defense if a patient or petient surrogate alleges nursing negligence.

Question 3

source- oriented record

Accepted Answer

each healthcare group keeps data on its own seperate form

Question 4

progress notes

Accepted Answer

notes written to inform caregivers of the progress a patient is making toward acheiving expectied outcomes

Question 5

narrative notes

Accepted Answer

pregress notes written by nurses in a source oriented record are narrative notes and address routine care, normal findings, and patient problems identified in the plan of care

Question 6

problem oriented medical record

Accepted Answer

is organzied around a patients problems rather than around sources of information

Question 7

SOAP

Accepted Answer

Subjective, Objective, Assessment, Plan is used during organization of a problem oriented medical record

Question 8

Pie Charting

Accepted Answer

does not develop a seperate plan of care, the plan of care is incorporated into the progress notes in which problems are identified by number

Question 9

focus charting

Accepted Answer

is to bring the focus of care back to the patient and the patients concerns

Question 10

DAR format

Accepted Answer

Data, Action, Response this format is used in the narative part in focus charting

Question 11

Charting by exception

Accepted Answer

shorthand documentation method that makes use of well defined standards of practice

Question 12

Collaborative pathways

Accepted Answer

caae management plan that is a detailed, standardized plan of care developed for a patient population with a designated dignosis or procedure; it includes expected outcomes, a list of interventions to be preformed and the seguence and timing

Question 13

variance charting

Accepted Answer

when a patient fails to meet an expected outcome of a planned intervention is not implemented in the case mangagement model this variance from the plan is documented

Question 14

minimum data sets

Accepted Answer

a standard established by healthcare institutions that specifies the information that must be collected from every patient

Question 15

computer based records

Accepted Answer

these data can be distributed among many caregivers in a standardized format, allowing them to compare and unifromly evaluate patient progress easily

Question 16

personal health records

Accepted Answer

many individuals today are preparing personal health records on the web to manage their healthcare via computer. these records contain the individuals medical history, including diagnoses, symptoms, and medication.

Question 17