Documentation
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| The person who is appointed to examine patients charts and health records to assess quality of care is known as ______________. | Auditors
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| The ___________is a system used to consolidate patient orders and care needs in a centralized, concise way. | Kardex (or Rand).
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| The five basic purposes of written patient records are: | 1) Written Communication 2) Permanent record for accountability 3) Legal Record of Care 4) Teaching 5) Research and Data Collection
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| How does home health care documentation relate to reimbursement? | Documentation provides the justification for reimbursement because nurses have to document all of their services for payment (e.g., direct skilled care, patient instructions, skilled observations, and evaluation visits).
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| A system that is used by medicare for reimbursement of patient care services is ____. | Diagnosis-related group.
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| The most accurate definition of the patient's chart is : | A legal record used to meet the many demands of the health system.
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| What is the purpose of an incident report? | 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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| An incident report is included as part of a person's medical record. True or False | False.
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| What is the relationship between Kardex and the patient's chart? | 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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| What are the advantages of computer documentation? | 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? | 1. programs need to be kept up to date with systems. 2. Training of personnel can take some time. 3. May use a unique language for that specific agency on that computer system. 4. Possible confidentiality concerns.
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| Focus charting contains ___________ and ___________. | Nursing action and patient response.
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| Charting by exception: | decreases the time needed to complete the nurse's notes.
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| What type of charting format usually requires the most time to complete? | Narrative
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| What type of charting format most reflects the nursing process? | Focus
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| What documentation is included in the "P" when using the PIE method of charting? | Problem List
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| The POMR is divided into which four major sections? | Database, problem list, (care) plan, and progress notes.
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| The problem oriented medical record does what? | 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 _______________. | Charting by Exception (CBE).
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| What are the basic guidelines for charting? | Correct spelling, punctuation, and grammar. Good penmanship Information is clear, concise, and accurate.
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| Confidentiality of a patient's medical record is guaranteed by? | HIPAA
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| Who owns a medical record/Health Care Record? | Institution or Physician
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| Patients have immediate access to their medical record. True or False | False. The only exception is VA hospitals.
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| What happens when an error is made by the nurse in charting? | 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: | assignment of individual passwords
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| Inadequate documentation that is commonly involved in cases of malpractice includes: | 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: | Use of approved medical terms and abbreviations are permitted.
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| patient healt care records are: | concise, legal records of all care given and responses.
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| When the POMR method is used for documentation: | 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 | subjective information the patient states or feels.
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| When charting the nurse should | 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: | read charts only for a professional reason.
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| The use of computers in the hospital by nurses: | can save on charting time once nurses are comfortable using computers.
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| When completing and incident report, the nurse is aware that it is necessary to: | Document facts regarding the incident.
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| Charting by exception documents those conditions, interventions, or outcomes outside the norm. True or False | True
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| What is a recommended guideline for charting? | Have the patient names and identification number on every sheet.
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| The 24-hour patient care record-keeping system is useful in | consolidating the nursing record.
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| Acuity charting requires what? | Staff to document their interventions.
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| Which accredidation agency specifies guidelines for documentation? | The Joint Commission (TJC)
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| When comparing documentation for acute care in hospitals with documentation for long-term care, majore diferences are related to : | The prospective payment system determing the standards for reimbursement.
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| What kind of documentation method describes occurences in chronological order? | Narrative documentation
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| Standards and policies regarding documentation in long-term care facilities is guided by _______. | MDS
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| The government reimburses agencies for health care costs incurred by Medicare and medicaid recipients based on ____________. | Diagnosis-related groups.
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| Auditors | people apointed to examine a patients charts and health records to assess quality of care.
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| Chart (Health Care Record) | Legal record that is used to meet many demands of the health accrfedidation, medical insurance, and legal systems.
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| Charting | Process of recording information on a patients chart.
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| Chart by Exception (CBE) | Recording only new data or changes in a patient status or care.
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| Database | Large store or bank of information.
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| Diagnosis Related Group (DRG) | System that classifies patients by age, diagnoses, and surgical categories.
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| Documenting | Process of adding information to the chart, usually at prescribed intervals.
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| Kardex (or RAND) | Card system used to consolidate patient orders and care needs in a centralized, concise way.
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| Narrative Charting | Nurse documents in story form all pertinent patient observations, care, and responses.
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| Nomenclature | A classified system of technical or scientific names and terminology.
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| Nursing Care Plan | Plan care based on Nursing assesment and nursing diagnosis
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| Nursing notes | Form on the patients chart on which nurses record their observations, care given, and the patients responses.
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| Peer Review | an appraisa by professional co-workers of equal status.
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| Problem List | Prioritized master list of the patients active, inactive, temporary, and at-rishk medical or other problems.
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| Problem-Oriented Medical Record (POMR) | Method of recording data about the health status of a patient in a problem-solving system.
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| Quality Assurance, Assesment, and improvement | An evaluation of services provided ana the results acheives as compared with accepted standards.
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| Recording | Process of adding written information to the chart, usually at prescribed intervals.
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| SOAPIER | USED IN POMR charting S - subjective O - Objective A - Assesment P - Plan I - Intervention E - Evaluation R - Revision
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| Traditional (block) chart | Traditional chart broken down into sections or blocks.
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Created by:
losmica
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