NUR 112 Exam 1 George C Wallace State Community
College-Hanceville | UPDATED Questions with 100% Verified Answers
Question:
Elements of Documentation (Guidelines)
Answer:
- accessible
- accurate
- relevant
- consistent
- auditable
- clear
- concise/ complete
- legible/readable
-thoughtful
- timely
- sequential
- reflective of the nursing process
- retrievable on a permanent basis in a nursing- specific manner.
Question:
Who should document?
Answer:
Whoever is responsible for the nurses care should chart but others can chart in as well.
Everyone should document!!!
Question:
Why should you document without error?
Answer:
Poor documentation can be presumed as medical negligence. "CYA".
Make sure you're documenting without error/ i.e. Don't document the wrong BP. Can
possibly affect medication dosage.
Errors make nurses look less credible. Which can affect credibility.
,Question:
What is informatics?
Answer:
computer and software systems (may include pager system any type of tech)
Question:
Should you skip lines if you're charting?
Answer:
No!
Question:
Approved abreviations
Answer:
A.C.- Before meals
b.i.d.- twice a day
c - with
D/C- discontinue or discharge
gtt, GTT- drops
IVPB- intravenous piggyback
mg-milligram
mcg- microgram
O.D.- right eye
O.S.- left eye
O.U.- both eyes
P- after
p.c.- after meals
PRN, p.r.n.- as needed
P.O., p.o.- by mouth
p.r., R- rectally
q.h.- every hour
q.i.d.- four times a day
QS- quantity sufficient
s- without
ss- one-half
,t.i.d.- three times a day
Question:
What is HIPAA
Answer:
Health Insurance Portability and Accountability Act
Question:
Potential Breaches in Patient Confidentiality
Answer:
Displaying information on a public screen
-Sending confidential e-mail messages via public networks
-Sharing printers among units with differing functions
-Discarding copies of patient information in trash cans
-Holding conversations that can be overheard
-Faxing confidential information to unauthorized persons
-Sending confidential messages overheard on pagers
Question:
Hypothetically, if a patient had yellow skin, was not wearing
pants, was smiling, and its stomach is sticking out, and the
patient also states, "I'm rumbly in my tummly." How would you
chart this?
Answer:
Patient has generalized jaundice. Ambulating in room. Patient is not wearing pants.
Protruding abdomen. The patient is smiling. No signs of distress. Patient states I'm rumbly
in my tummy. Patient "I'm hungry".
Question:
Patient's have the right to:
Answer:
-See and copy their health record
-Update their health record
, -Get a list of disclosures
-Request a restriction on certain uses or disclosures
-Choose how to receive health information
Question:
what can patient's NOT do to their paperwork?
Answer:
patient's cannot revise info
Question:
Documentation
Answer:
written or electronic legal record kept by nurses for assessing and planning
Question:
What is the nursing process?
Answer:
Assessment
Diagnosis
Planning
Implementation
Evaluation
Question:
content must be factual - meaning what can you see?
Answer:
examples: Shortness of breath, cardiac arrest, patient is in use of oxygen with 2 Liters,
etc.
Question:
Factual charting example vs. not
Answer:
College-Hanceville | UPDATED Questions with 100% Verified Answers
Question:
Elements of Documentation (Guidelines)
Answer:
- accessible
- accurate
- relevant
- consistent
- auditable
- clear
- concise/ complete
- legible/readable
-thoughtful
- timely
- sequential
- reflective of the nursing process
- retrievable on a permanent basis in a nursing- specific manner.
Question:
Who should document?
Answer:
Whoever is responsible for the nurses care should chart but others can chart in as well.
Everyone should document!!!
Question:
Why should you document without error?
Answer:
Poor documentation can be presumed as medical negligence. "CYA".
Make sure you're documenting without error/ i.e. Don't document the wrong BP. Can
possibly affect medication dosage.
Errors make nurses look less credible. Which can affect credibility.
,Question:
What is informatics?
Answer:
computer and software systems (may include pager system any type of tech)
Question:
Should you skip lines if you're charting?
Answer:
No!
Question:
Approved abreviations
Answer:
A.C.- Before meals
b.i.d.- twice a day
c - with
D/C- discontinue or discharge
gtt, GTT- drops
IVPB- intravenous piggyback
mg-milligram
mcg- microgram
O.D.- right eye
O.S.- left eye
O.U.- both eyes
P- after
p.c.- after meals
PRN, p.r.n.- as needed
P.O., p.o.- by mouth
p.r., R- rectally
q.h.- every hour
q.i.d.- four times a day
QS- quantity sufficient
s- without
ss- one-half
,t.i.d.- three times a day
Question:
What is HIPAA
Answer:
Health Insurance Portability and Accountability Act
Question:
Potential Breaches in Patient Confidentiality
Answer:
Displaying information on a public screen
-Sending confidential e-mail messages via public networks
-Sharing printers among units with differing functions
-Discarding copies of patient information in trash cans
-Holding conversations that can be overheard
-Faxing confidential information to unauthorized persons
-Sending confidential messages overheard on pagers
Question:
Hypothetically, if a patient had yellow skin, was not wearing
pants, was smiling, and its stomach is sticking out, and the
patient also states, "I'm rumbly in my tummly." How would you
chart this?
Answer:
Patient has generalized jaundice. Ambulating in room. Patient is not wearing pants.
Protruding abdomen. The patient is smiling. No signs of distress. Patient states I'm rumbly
in my tummy. Patient "I'm hungry".
Question:
Patient's have the right to:
Answer:
-See and copy their health record
-Update their health record
, -Get a list of disclosures
-Request a restriction on certain uses or disclosures
-Choose how to receive health information
Question:
what can patient's NOT do to their paperwork?
Answer:
patient's cannot revise info
Question:
Documentation
Answer:
written or electronic legal record kept by nurses for assessing and planning
Question:
What is the nursing process?
Answer:
Assessment
Diagnosis
Planning
Implementation
Evaluation
Question:
content must be factual - meaning what can you see?
Answer:
examples: Shortness of breath, cardiac arrest, patient is in use of oxygen with 2 Liters,
etc.
Question:
Factual charting example vs. not
Answer:
