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Chapter 9 Docum.
Fundamentals - Documentation
| Question | Answer |
|---|---|
| What is collections of information about a person's health, the care provided by health practitioners, and the client's progress? | Medical record |
| What are the 7 uses of the medical record? | 1.permanent record 2. sharing info 3. quality assurance 4.accrediation 5. reimbursement 6.education & research 7.legal evidence |
| Accrediation is done by who? | Joint Commission |
| What are the 2 types of client records? | 1.source-oriented records 2.problem-oriented records |
| What are the 4 major components of problem-oriented records? | 1.database 2.problem list 3.plan of care 4.progress notes |
| What are the 6 methods of charting? | 1.Narrative 2.SOAP 3.Focus 4.PIE 5.Charting by exception 6.Computerized |
| What method of charting generally uses source-oriented records and involves writing information about client & client care in chronological order? | Narrative Charting |
| What method of charting is more likely to be used in a problem-oriented record? | SOAP Charting |
| What does SOAP stand for? | S= Subjective data; O= Objective data; A= Analysis of the data; P= plan of care |
| Can a medical record be tampered with? Why or why not? | No because it is a legal document. |
| What does HIPAA stand for? | Health Insurance Portability and Accountability Act |
| What method of charting is a modified form of SOAP charting? | Focus Charting |
| What method of charting also follows a DAR model? What does DAR stand for? | Focus Charting; D=data, A=action, R=response |
| What method of charting records the client's progress under the headings of problems, intervention, and evaluation? | PIE Charting |
| What documentation or method of charting is when a nurse charts only abnormal findings or care that deviates from the standard? | Charting by exception |
| What documentation is done electronically and is the most efficient for nurses when documenting at the point of care or bedside? | Computerized Charting |
| What are exemptions when agencies can release private health information without the client's prior authorization? | beneficial disclosures |
| What must you do when charting subjective data or what the client says he/she feels? | Always use quotation marks around the statement the patient/client makes about they feel or what they say. |
| What is the #1 way for a nurse to protect his/her self from a malpractice lawsuit? | Good documentation |
| JCAHO stands for? | Joint Commission on Accrediation of Healthcare Organization |
| What are the components of a medical record? | Person's health information, care provided by health practitioner, client's progress, plan of care, medication administration record (MAR), laboratory/diagnostic reports |
| If you forget to document at the moment you complete a task/care for your patient you must do what? | You must enter it as a LATE ENTRY! |
| When making a mistake in documenting in a patient's chart what must you do? | MArk through it with only one line and initial it. |
| If something happens to your patient or something like a reaction to a medication, what must you do? | Contact family of the patient. |
| When taking a physician's order what important thing MUST you do? | Read and clarify the order that the physician gave you and document that you read back and it was clarified. |
| What is a quick reference for current information about the client and his or her care? | Kardex |
| What is a form of documentation in which a nurse indicates with initials the performance of a routine task? | Checklists |
| What does the Joint Commission's standards require that the record show evidence of? | A plan of care |
| What is the form of documentation with sections for recording frequently repeated assessment data? | Flow Sheet |
| What are walking rounds? | Giving the report in a client's presence with the oncoming shift nurse. |
| NKA | no known allergies |
| NSS | normal saline solution |
| OOB | out of bed |
| a.c. | before meals |
| p.c. | after meals |
| stat | immediately |
| via | by way of |
| t.i.d | three times a day |
| b.i.d. | twice a day |
| BRP | bathroom privileges |
| ED | emergency department |
| BM | bowel movement |
| NPO | nothing by mouth |
| I & O | intake and output |
| et | and |
| c/o | complains of |
| CCU | coronary care unit |
| ad lib | as desired |
| AMA | against medical advice |
| po | by mouth |
| UA | urinalysis |
| WNL | within normal limits |
| WC | wheelchair |
| NANDA | North American Nursing Diagnosis Association |
| MAR | medication administration record |
| What are the 3 extended care facilities? | 1.skilled nursing facilities 2.intermediate care facilities 3.basic care facilities |
| MDS | minimum data set |
Created by:
CrissyEllen
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