NURB 240 Exam 1 Questions and Answers| New Update with 100% Correct Answers
differences between documenting and reporting Documentation:
1. charting
2. entering information into a permanent client record
3. usually computer based
4. multiple formats used within EHRs
Reporting:
1. used to pass information to others
2. may be verbal (in-person, by phone, or recorded), written, or computerized
3. not typically considered part of the permanent record
4. format may be standardized
why do you have to be very careful about what you write when you're charting/ documenting?
it is permanent!! and a lot of other people will have the ability to read it
purposes of charting 1. interprofessional communication to the healthcare team
2. legal documentation: if you didn't chart it, you didn't do it!
3. financial reimbursement: it's how they bill the insurance, based on the level of care the
patients required and received
4. auditing and monitoring to identify areas for improvement
basic rules of documentation 1. if it wasn't charted, it wasn't done
2. if you didn't do it, don't chart it
3. never chart ahead
4. never chart for someone else
5. be cautious about using copy and paste
6. designate AM or PM or use military time
,7. spelling counts!
8. be concise and precise
9. no negative judgments/ criticisms of the patient or family
10. your opinion of an applicable nursing diagnosis is perfectly fine/ encouraged, but should be
supported by evidence from your assessment findings
11. paper charting: dark ink, legible, NO BLANK SPACE (to keep people from coming in and
charting after you)
types of documentation 1. flow sheets
2. narrative charting
flow sheets 1. most common in EHRs from clinicals: assessments, vitals, safety checks, ADLs,
I & O, MARs
2. providing information without context
3. may or may not include charting by exception
4. when charting by exception is used, the WDL/ WNL findings must be included within the
flowsheet
5. can include small comments within the flowsheet when needed
what is charting by exception commonly used in assessments: can check a box indicating
that all aspects of the body system were assessed and within normal limits, would do a more
detailed check boxes or narrative note for aspects of the physical assessment that aren't normal
ex. neuro check is WNL, but if they weren't oriented x4 you would have to check that it was not
normal and then continue checking boxes for what was abnormal
narrative charting 1. telling a story
2. several standardized formats, but we use SOAP
3. used in any situation where something unusual/ unexpected happens or when you need to
communicate with a provider
,SOAP charting S: subjective data: things the patient says
O: objective data: things you observe (vital signs, lab results, physical assessment findings)
A: assessment: interpret the subjective and objective data; state the problem or note client
progress on the problem; may be in the form of a nursing diagnosis: THIS IS NOT A PHYSICAL
ASSESSMENT AND YOU CANNOT HAVE A MEDICAL DIAGNOSIS HERE
P: plan: plan of care to address the problem
Receiving telephone/ verbal orders 1. less popular with increasing use of computerized
physician order entry (CPOE)
2. know agency policy
3. closed loop communication
4. will be documented on a special EHR page or paper form
5. all orders should have a date/time, order details, indication that the order was read back to
provider, name of person giving order, signature with credentials
closed loop communication always write down the order, read it back to the prescriber, and
ask for verification
required components for telephone/ verbal orders 1. date and time
2. order details (including frequency)
3. indication that the order was read back to the provider
4. name of the person giving the order
5. your signature with credentials
, abbreviations for receiving telephone/ verbal orders 1. RVVO
2. RVTO
3. TORB
4. VORB
RVVO read back and verified verbal order (standing in same room and speaks to you)
RVTO read back and verified telephone order
TORB telephone order read back
VORB verbal order read back
prohibited abbreviations 1. U
2. IU
3. QD, QOD
4. trailing zero
5. lack of leading zero
6. MS, MS04, MgS04
7. μg
8. cc
9. AS, AD, AU, OS, OD, OU
10. ambivalent duration
11. SQ, SC
Prohibited abbreviation: U
differences between documenting and reporting Documentation:
1. charting
2. entering information into a permanent client record
3. usually computer based
4. multiple formats used within EHRs
Reporting:
1. used to pass information to others
2. may be verbal (in-person, by phone, or recorded), written, or computerized
3. not typically considered part of the permanent record
4. format may be standardized
why do you have to be very careful about what you write when you're charting/ documenting?
it is permanent!! and a lot of other people will have the ability to read it
purposes of charting 1. interprofessional communication to the healthcare team
2. legal documentation: if you didn't chart it, you didn't do it!
3. financial reimbursement: it's how they bill the insurance, based on the level of care the
patients required and received
4. auditing and monitoring to identify areas for improvement
basic rules of documentation 1. if it wasn't charted, it wasn't done
2. if you didn't do it, don't chart it
3. never chart ahead
4. never chart for someone else
5. be cautious about using copy and paste
6. designate AM or PM or use military time
,7. spelling counts!
8. be concise and precise
9. no negative judgments/ criticisms of the patient or family
10. your opinion of an applicable nursing diagnosis is perfectly fine/ encouraged, but should be
supported by evidence from your assessment findings
11. paper charting: dark ink, legible, NO BLANK SPACE (to keep people from coming in and
charting after you)
types of documentation 1. flow sheets
2. narrative charting
flow sheets 1. most common in EHRs from clinicals: assessments, vitals, safety checks, ADLs,
I & O, MARs
2. providing information without context
3. may or may not include charting by exception
4. when charting by exception is used, the WDL/ WNL findings must be included within the
flowsheet
5. can include small comments within the flowsheet when needed
what is charting by exception commonly used in assessments: can check a box indicating
that all aspects of the body system were assessed and within normal limits, would do a more
detailed check boxes or narrative note for aspects of the physical assessment that aren't normal
ex. neuro check is WNL, but if they weren't oriented x4 you would have to check that it was not
normal and then continue checking boxes for what was abnormal
narrative charting 1. telling a story
2. several standardized formats, but we use SOAP
3. used in any situation where something unusual/ unexpected happens or when you need to
communicate with a provider
,SOAP charting S: subjective data: things the patient says
O: objective data: things you observe (vital signs, lab results, physical assessment findings)
A: assessment: interpret the subjective and objective data; state the problem or note client
progress on the problem; may be in the form of a nursing diagnosis: THIS IS NOT A PHYSICAL
ASSESSMENT AND YOU CANNOT HAVE A MEDICAL DIAGNOSIS HERE
P: plan: plan of care to address the problem
Receiving telephone/ verbal orders 1. less popular with increasing use of computerized
physician order entry (CPOE)
2. know agency policy
3. closed loop communication
4. will be documented on a special EHR page or paper form
5. all orders should have a date/time, order details, indication that the order was read back to
provider, name of person giving order, signature with credentials
closed loop communication always write down the order, read it back to the prescriber, and
ask for verification
required components for telephone/ verbal orders 1. date and time
2. order details (including frequency)
3. indication that the order was read back to the provider
4. name of the person giving the order
5. your signature with credentials
, abbreviations for receiving telephone/ verbal orders 1. RVVO
2. RVTO
3. TORB
4. VORB
RVVO read back and verified verbal order (standing in same room and speaks to you)
RVTO read back and verified telephone order
TORB telephone order read back
VORB verbal order read back
prohibited abbreviations 1. U
2. IU
3. QD, QOD
4. trailing zero
5. lack of leading zero
6. MS, MS04, MgS04
7. μg
8. cc
9. AS, AD, AU, OS, OD, OU
10. ambivalent duration
11. SQ, SC
Prohibited abbreviation: U
