NUFT 204 EXAM REVIEW UPDATED QUESTIONS AND
ANSWERS SURE A+
✔✔Confer - ✔✔to consult with someone to exchange ideas or to seek information,
advice, or instructions
✔✔Consultation - ✔✔process in which two or more individuals with varying degrees of
experience and expertise deliberate about a problem and its solution
✔✔Critical/collaborative Pathway - ✔✔case management plan that is detailed,
standardized plan of care developed for a patient population with a designated
diagnosis or procedure; it includes expected outcomes, a list of interventions to be
performed, and the sequence and timing of those interventions
✔✔Discharge Summary - ✔✔description of where the patient stands in relation to
problems identified in the record at discharge; documents any special teaching or
counseling the patient received, including referrals
✔✔Documentation - ✔✔written, legal record of all pertinent interventions with the
patient---assessments, diagnoses, plans, interventions, and evaluations
✔✔Electronic Health Record (EHR)/Electronic Medical Record (EMR) - ✔✔computer-
based record of data that can be distributed among many caregivers in a standardized
format
✔✔Flow Sheet - ✔✔graphic record of abbreviated aspects of patient's condition (e.g.,
vital signs, routine aspects of care)
✔✔Focus Charting - ✔✔a documentation system that replaces the problem list with a
focus column that incorporates many aspects of a patient and patient care; the focus
may be a patient strength or a problem or need; the narrative portion of focus charting
uses the data (D), action (A), response (R) format
✔✔Hand-off - ✔✔A nurses report to another nurse or healthcare provider about a
patient status or progress
✔✔Health information exchange (HIE) - ✔✔an electronic system that allows physicians,
nurses, pharmacists, and other health care providers, and patients to appropriately
access and securely share the patient's vital medical information
✔✔Incident/variance Report - ✔✔a report of any event that is not consistent with the
routine operation of the health care agency that results in or has the potential to result in
harm to a patient, employee, or visitor
, ✔✔ISBARR communication - ✔✔a process for effective hand-off communication among
health care professionals about a patient's condition, standing for Identity/Introduction,
Situation, Background, Assessment, Recommendation, and Read back.
✔✔Meaningful use - ✔✔the use of certified electronic health record technology to
achieve health and efficiency goals, with a financial incentive from Medicare and
Medicaid
✔✔Narrative notes - ✔✔progress notes written by nurses in a source-oriented record
✔✔Nursing informatics - ✔✔A specialty that integrates nursing science, computer
science, and information science to manage and communicate data, information, and
knowledge in nursing practice.
✔✔Outcome and Assessment Information Set (OASIS) - ✔✔assessment instrument
representing core items of comprehensive assessment for adult non maternity home
healthcare patients that forms the basis for measuring
✔✔Occurrence/variance charting - ✔✔When a patient fails to meet an expected
outcome or a planned intervention is not implemented, including the unexpected event,
the cause of the event, actions taken in response of the event and discharge planning
when appropriate. Usually used for variances that affect quality, cost, or length of stay
✔✔Patient record - ✔✔a compilation of a patient's health information; the patient record
is the only permanent legal document that details the nurse's interactions with the
patient
✔✔Personal health record (PHR) - ✔✔information sheets that contain the individual's
medical history, including diagnoses, symptoms, and medications
✔✔PIE Charting - ✔✔documentation system that does not develop a separate care
plan; the care plan is incorporated into the progress notes in which problems are
identified by number, worked up using the problem (P), intervention (I), evaluation(E)
format, and evaluated each shift
✔✔Problem-oriented medical record (POMR) - ✔✔documentation system organized
according to the persons specific health problems; includes database,problem list, plan
of care and progress notes
✔✔Progress notes - ✔✔any of a variety of methods of notes that relate how a patient is
progressing toward expected outcomes
✔✔Read Back - ✔✔a process in which a nurse and other health care provider repeats a
verbal order back to a physician to ensure that it was correctly heard or interpreted
ANSWERS SURE A+
✔✔Confer - ✔✔to consult with someone to exchange ideas or to seek information,
advice, or instructions
✔✔Consultation - ✔✔process in which two or more individuals with varying degrees of
experience and expertise deliberate about a problem and its solution
✔✔Critical/collaborative Pathway - ✔✔case management plan that is detailed,
standardized plan of care developed for a patient population with a designated
diagnosis or procedure; it includes expected outcomes, a list of interventions to be
performed, and the sequence and timing of those interventions
✔✔Discharge Summary - ✔✔description of where the patient stands in relation to
problems identified in the record at discharge; documents any special teaching or
counseling the patient received, including referrals
✔✔Documentation - ✔✔written, legal record of all pertinent interventions with the
patient---assessments, diagnoses, plans, interventions, and evaluations
✔✔Electronic Health Record (EHR)/Electronic Medical Record (EMR) - ✔✔computer-
based record of data that can be distributed among many caregivers in a standardized
format
✔✔Flow Sheet - ✔✔graphic record of abbreviated aspects of patient's condition (e.g.,
vital signs, routine aspects of care)
✔✔Focus Charting - ✔✔a documentation system that replaces the problem list with a
focus column that incorporates many aspects of a patient and patient care; the focus
may be a patient strength or a problem or need; the narrative portion of focus charting
uses the data (D), action (A), response (R) format
✔✔Hand-off - ✔✔A nurses report to another nurse or healthcare provider about a
patient status or progress
✔✔Health information exchange (HIE) - ✔✔an electronic system that allows physicians,
nurses, pharmacists, and other health care providers, and patients to appropriately
access and securely share the patient's vital medical information
✔✔Incident/variance Report - ✔✔a report of any event that is not consistent with the
routine operation of the health care agency that results in or has the potential to result in
harm to a patient, employee, or visitor
, ✔✔ISBARR communication - ✔✔a process for effective hand-off communication among
health care professionals about a patient's condition, standing for Identity/Introduction,
Situation, Background, Assessment, Recommendation, and Read back.
✔✔Meaningful use - ✔✔the use of certified electronic health record technology to
achieve health and efficiency goals, with a financial incentive from Medicare and
Medicaid
✔✔Narrative notes - ✔✔progress notes written by nurses in a source-oriented record
✔✔Nursing informatics - ✔✔A specialty that integrates nursing science, computer
science, and information science to manage and communicate data, information, and
knowledge in nursing practice.
✔✔Outcome and Assessment Information Set (OASIS) - ✔✔assessment instrument
representing core items of comprehensive assessment for adult non maternity home
healthcare patients that forms the basis for measuring
✔✔Occurrence/variance charting - ✔✔When a patient fails to meet an expected
outcome or a planned intervention is not implemented, including the unexpected event,
the cause of the event, actions taken in response of the event and discharge planning
when appropriate. Usually used for variances that affect quality, cost, or length of stay
✔✔Patient record - ✔✔a compilation of a patient's health information; the patient record
is the only permanent legal document that details the nurse's interactions with the
patient
✔✔Personal health record (PHR) - ✔✔information sheets that contain the individual's
medical history, including diagnoses, symptoms, and medications
✔✔PIE Charting - ✔✔documentation system that does not develop a separate care
plan; the care plan is incorporated into the progress notes in which problems are
identified by number, worked up using the problem (P), intervention (I), evaluation(E)
format, and evaluated each shift
✔✔Problem-oriented medical record (POMR) - ✔✔documentation system organized
according to the persons specific health problems; includes database,problem list, plan
of care and progress notes
✔✔Progress notes - ✔✔any of a variety of methods of notes that relate how a patient is
progressing toward expected outcomes
✔✔Read Back - ✔✔a process in which a nurse and other health care provider repeats a
verbal order back to a physician to ensure that it was correctly heard or interpreted
