test 1
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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| Purpose of the chart | communication, permanent record for accountability, peer review, reimbursement, legal record of care, teaching tool, and research and data collection
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| Types of patient records | source-oriented and problem-oriented
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| source-oriented chart | each healthcare discipline documents in their own section
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| Problem-oriented chart | based on scientific problem-solving method; organized according to the health problem
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| problem oriented chart includes | database,problem list, plan of care, and progress notes (everybody documents here)
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| methods of charting | narrative style, SOAPE/SOAPIER, Focus, PIE, charting by exception
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| charting by exception | only abnormal assessment findings are documented; effort to decrease length and repetition
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| PIE charting | Problem Intervention Evaluation
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| Focus charting DARE | Data Action Response Education
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| SOAPE/SOAPIER charting | Subjective Objective Assessment Plan Evaluation Intervention Revision
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| Narrative charting | descriptive form including pt. problem, care and treatment provided; as well as pt. response
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| computer charting pros/cons | PROS fast, legible, auto date/time
CONS can risk confidentiality, can be hard to make corrections if not made quickly
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| T or F never use military time | False
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| 00:00= | midnight or 12am
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| 12:00= | 12pm or noon
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| 18:00= | 6pm
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| 23:00= | 11pm
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| 1am | 01:00
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| 6am | 06:00
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| T or F Rn is responsible for initial assessment upon admission | True
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| T or F any sheet patient info is documented on may only include the patient date of birth | False. It should have their at least their name on every page
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| T or F when in doubt write it out | True
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| when giving medications, especially PRN... | Always chart follow-up response 30 minutes after
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| T or F Empty lines in a chart are okay if there is nothing to note | False. Any skipped lines or empty lines should at least have a line drawn through them to avoid additions at later times.
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| T or F chart as soon as you can, even if it is prior to giving care | False. only chart after care is given and as soon as possible after
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| Do you have to chart the type of transportation device used to transfer or discharge a pt.? | yes.
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| Can you chart deviations without and explanation? | No. there needs to always be an explanation of any deviations from the original care plan.
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| should you document any time the physician was contacted? | Yes.
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Created by:
laceynickie
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