Documentation
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| The person who is appointed to examine patients charts and health records to assess quality of care is known as ______________. | show 🗑
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| show | Kardex (or Rand).
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| The five basic purposes of written patient records are: | show 🗑
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| How does home health care documentation relate to reimbursement? | show 🗑
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| A system that is used by medicare for reimbursement of patient care services is ____. | show 🗑
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| show | A legal record used to meet the many demands of the health system.
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| show | A record of any event that is not consistent with the routine operation of a health care unit or the routine care of a patient. THIS INFORMATION HELPS THE FACILITY RISH MANAGER AND UNIT MANAGERS PREVENT FUTURE PROBLEMS THROUGH EDUCATION AND OTHER MEASURES
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| show | False.
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| show | The Kardex contains cumulative information based on the information required for care from the patients chart in a quick reference format at the nurse's station.
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| show | 1. eliminate repetitive entries 2. freedom to access the database. 3. Allows for quick interaction between various departments (lab, dr, pharmacy, billing, etc. 4. Easy to transfer as it is electronic.
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| What are the disadvantages of computer documentation? | show 🗑
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| show | Nursing action and patient response.
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| show | decreases the time needed to complete the nurse's notes.
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| show | Narrative
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| show | Focus
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| show | Problem List
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| show | Database, problem list, (care) plan, and progress notes.
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| show | It uses a patient problem list as an index for chart documentation.
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| The charting format most commonly used for documentation of clinical pathways is _______________. | show 🗑
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| What are the basic guidelines for charting? | show 🗑
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| Confidentiality of a patient's medical record is guaranteed by? | show 🗑
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| Who owns a medical record/Health Care Record? | show 🗑
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| show | False. The only exception is VA hospitals.
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| show | A line is drawn through the error and initialed, and then the nurse continues with the charting.
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| Confidentiality is most often maintained with use of computer charting through the: | show 🗑
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| show | 1. documenting incorrect data 2. charting nursing actions in advance 3. charting incorrect times at which events occurred. 4. failing to record verbal orders or failing to havbe them signed.
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| When documenting care and observations in a patient record: | show 🗑
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| show | concise, legal records of all care given and responses.
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| show | the charting format is SOAPE or SOAPIER
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| The nurse is usint the SOAPE method to chart. In this method the S stands for | show 🗑
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| show | chart as soon and as often as necessary.
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| Understanding that health care personnel must respect the confidentiality of patients records, the nurse should: | show 🗑
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| The use of computers in the hospital by nurses: | show 🗑
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| When completing and incident report, the nurse is aware that it is necessary to: | show 🗑
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| Charting by exception documents those conditions, interventions, or outcomes outside the norm. True or False | show 🗑
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| show | Have the patient names and identification number on every sheet.
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| show | consolidating the nursing record.
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| show | Staff to document their interventions.
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| Which accredidation agency specifies guidelines for documentation? | show 🗑
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| show | The prospective payment system determing the standards for reimbursement.
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| show | Narrative documentation
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| Standards and policies regarding documentation in long-term care facilities is guided by _______. | show 🗑
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| The government reimburses agencies for health care costs incurred by Medicare and medicaid recipients based on ____________. | show 🗑
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| show | people apointed to examine a patients charts and health records to assess quality of care.
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| show | Legal record that is used to meet many demands of the health accrfedidation, medical insurance, and legal systems.
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| show | Process of recording information on a patients chart.
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| Chart by Exception (CBE) | show 🗑
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| show | Large store or bank of information.
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| show | System that classifies patients by age, diagnoses, and surgical categories.
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| Documenting | show 🗑
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| show | Card system used to consolidate patient orders and care needs in a centralized, concise way.
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| show | Nurse documents in story form all pertinent patient observations, care, and responses.
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| Nomenclature | show 🗑
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| Nursing Care Plan | show 🗑
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| show | Form on the patients chart on which nurses record their observations, care given, and the patients responses.
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| Peer Review | show 🗑
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| Problem List | show 🗑
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| Problem-Oriented Medical Record (POMR) | show 🗑
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| Quality Assurance, Assesment, and improvement | show 🗑
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| Recording | show 🗑
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| show | USED IN POMR charting S - subjective O - Objective A - Assesment P - Plan I - Intervention E - Evaluation R - Revision
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| show | Traditional chart broken down into sections or blocks.
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Created by:
losmica
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