nursing documentation
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
|
|
||||
|---|---|---|---|---|---|
| 8 reasons for documentation | communication, education, assessments & planning, research, auditing, legal documentation, agency accreditation, reimbursement
🗑
|
||||
| flow sheets | repetitive documentation, quick reference, faster documentation, MAR, nursing care for 24 hours, VS
🗑
|
||||
| narrative charting | summary of routine care, normal findings, patient problems. chronological order.
🗑
|
||||
| charting sequence | describe the assessment of patient, nursing interventions, evaluation
🗑
|
||||
| charting | concise, accurate, factual, written documentation and communication of occurrences and situations pertaining to a patient
🗑
|
||||
| federal statutes | medicare, medicaid
🗑
|
||||
| state statutes | nurse practice act, department of health
🗑
|
||||
| JCAHO | joint commission on accreditation of healthcare organizations
🗑
|
||||
| problem oriented medical record | data is arranged according to the problem the patient rather than the source of the information
🗑
|
||||
| charting by exception | documentation system in which only abnormal or significant findings or exceptions to norms are recorded
🗑
|
||||
| computerized charting | use computers to store patients database, add new data, create and revise care plans and document patients progress
🗑
|
||||
| the following information should be charted | doctor visit, calls to MD, stat meds, prn meds, treatments, refusal of meds or treatments
🗑
|
||||
| charting and the nursing process | nursing process provides the framework for decision making throughout all phases of nursing care. relate the nursing process and charting in the patient record
🗑
|
||||
| standard of care | detailed guidelines that represent the predicted care indicated in a situation, define professional practice and nursing care, care/critical pathways
🗑
|
||||
| source orientated medical records | each person or department makes notation in a separate section of patient chart, information about a problem is distributed throughout the record
🗑
|
||||
| nursing kardex | medical diagnosis, info needed for daily care, accessible, written plan of care, diet, activity, orders, saftey precautions, scheduled tests and procedures
🗑
|
Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Created by:
kamia2010
Popular Nursing sets