Theory Exam 3 NU 136 Galen exam with complete solution graded A+

What are the 5 steps in the nursing process? - Assessment Diagnosis Planning Implementation Evaluation What is the assessment portion of the nursing process used for? - data collection what is the nursing diagnosis portion of the nursing process used for? - analyzing the data what is the planning portion of the nursing process used for? - the steps to resolve the health problem present what is the implementation portion of the nursing process used for? - carrying out the steps of the planning portion what is the evaluation portion of the nursing process used for? - to assess the patients respose to the treatment How often is the nursing care plan updated? - every 24 hours what are the three charecteristics of an expected outcome? - realistic, attainable, and have a set timeline Who should have access to the patients records? - only those who are directly involved in the patients careWhat is source-oriented or narrative charting? - organized according to the source of the information What is problem-oriented medical record charting (POMR)? - charting the focuses on the patient's status with an emphasis on the problem-solving approach What is problem identification, interventions, and evaluation charting (PIE)? - follows the nursing process and uses nursing diagnosises while placing the plan of care within the nurses progress notes What is focused charting? - focuses only on the direct health problems of the patient What is charting by exception? - the assumption that all standards of practice are carried out and met with a normal or expected response What is computer-assisted charting or an electronic health record (EHR)? - a computerized comprehensive record of a patient's history and care across all facilities and admissions What is a computerized provider order entry (CPOE)? - an efficent and effective way for any orders put in through the system to be automatically sent to the appropriate clinical areas for action What is case management system charting? - organizing patient care through an episode of illness so that clinical outcomes are achieved within an expected time frame and at a predictable cost What do you never do when documenting on a computer? - walk away with the screen opened and unlocked What does accuracy in documentation mean? - being specific and definite in using words or phrases that convey the meaning you wish expressed What is brevity in documentation? - sentences are not neccessary, but abbreviations, acronymns, and symbols are acceptable