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 |