Fundamentals - Documentation
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| What is collections of information about a person's health, the care provided by health practitioners, and the client's progress? | Medical record
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| 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
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| Accrediation is done by who? | Joint Commission
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| What are the 2 types of client records? | 1.source-oriented records 2.problem-oriented records
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| What are the 4 major components of problem-oriented records? | 1.database 2.problem list 3.plan of care 4.progress notes
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| What are the 6 methods of charting? | 1.Narrative 2.SOAP 3.Focus 4.PIE 5.Charting by exception 6.Computerized
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| What method of charting generally uses source-oriented records and involves writing information about client & client care in chronological order? | Narrative Charting
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| What method of charting is more likely to be used in a problem-oriented record? | SOAP Charting
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| What does SOAP stand for? | S= Subjective data; O= Objective data; A= Analysis of the data; P= plan of care
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| Can a medical record be tampered with? Why or why not? | No because it is a legal document.
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| What does HIPAA stand for? | Health Insurance Portability and Accountability Act
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| What method of charting is a modified form of SOAP charting? | Focus Charting
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| What method of charting also follows a DAR model? What does DAR stand for? | Focus Charting; D=data, A=action, R=response
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| What method of charting records the client's progress under the headings of problems, intervention, and evaluation? | PIE Charting
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| What documentation or method of charting is when a nurse charts only abnormal findings or care that deviates from the standard? | Charting by exception
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| What documentation is done electronically and is the most efficient for nurses when documenting at the point of care or bedside? | Computerized Charting
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| What are exemptions when agencies can release private health information without the client's prior authorization? | beneficial disclosures
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| 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.
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| What is the #1 way for a nurse to protect his/her self from a malpractice lawsuit? | Good documentation
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| JCAHO stands for? | Joint Commission on Accrediation of Healthcare Organization
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| 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
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| 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!
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| 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.
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| If something happens to your patient or something like a reaction to a medication, what must you do? | Contact family of the patient.
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| 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.
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| What is a quick reference for current information about the client and his or her care? | Kardex
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| What is a form of documentation in which a nurse indicates with initials the performance of a routine task? | Checklists
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| What does the Joint Commission's standards require that the record show evidence of? | A plan of care
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| What is the form of documentation with sections for recording frequently repeated assessment data? | Flow Sheet
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| What are walking rounds? | Giving the report in a client's presence with the oncoming shift nurse.
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| NKA | no known allergies
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| NSS | normal saline solution
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| OOB | out of bed
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| a.c. | before meals
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| p.c. | after meals
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| stat | immediately
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| via | by way of
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| t.i.d | three times a day
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| b.i.d. | twice a day
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| BRP | bathroom privileges
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| ED | emergency department
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| BM | bowel movement
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| NPO | nothing by mouth
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| I & O | intake and output
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| et | and
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| c/o | complains of
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| CCU | coronary care unit
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| ad lib | as desired
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| AMA | against medical advice
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| po | by mouth
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| UA | urinalysis
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| WNL | within normal limits
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| WC | wheelchair
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| NANDA | North American Nursing Diagnosis Association
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| MAR | medication administration record
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| What are the 3 extended care facilities? | 1.skilled nursing facilities 2.intermediate care facilities 3.basic care facilities
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| MDS | minimum data set
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