NURS 122 Lecture WEEK 1 Verified Study Solutions With
Latest Tests
discussion - Answer-an informal oral consideration of a subject by two or more
healthcare personnel to identify a problem or establish strategies
/.report - Answer-oral, written, or computer-based communication intended to convey
information to others
/.The process of making an entry on a patient record is called - Answer-recording,
charting, or documenting
/.clinical record - Answer-a formal, legal document that provides evidence of a patient's
care
/."The nurse has a duty to maintain confidentiality of all patient information" is said by
who? - Answer-The American Nurses Association (ANA) Code of Ethics
/.PHI is the abbreviation for - Answer-Protected Health Information
/.purposes of patient records include - Answer-communication, planning patient care,
auditing health agencies, research, education, reimbursement, legal documentation,
healthcare analysis
/.the traditional patient record is called - Answer-a source-oriented record
/.narrative charting consists of what? - Answer-Written notes which include routine care,
normal findings, and patient problems
/.examples of diagnostic reports are - Answer-laboratory reports, x-ray reports, CT scan
reports
/.examples of consultation reports are - Answer-physical therapy and respiratory
therapy
/.the abbreviation for POMR is - Answer-problem-oriented medical record
/.what is a POMR? - Answer-data is arranged according to the problems the patient has
rather than according to the source of the information
/.what are some advantages and disadvantages of a POMR? - Answer-advantages:
they encourage collaboration, and that the problem list in the front of the chart alerts
caregivers to the patient's needs, making it easier to track the status of each problem
, disadvantages: not all caregivers can use the charting format effectively, constant
vigilance is required to maintain an up-to-date problem list which can be inefficient
/.what is a database? - Answer-all information known about the patient
/.SOAP is an acronym for - Answer-subjective, objective, assessment, and planning
/.subjective data - Answer-what the person says about himself or herself during history
taking
/.objective data - Answer-information that is seen, heard, felt, or smelled by an observer;
signs
/.assessment - Answer-interpretation or conclusions drawn about the subjective and
objective data
/.interventions - Answer-actions taken to correct or manage a patient's problems
/.evaluation - Answer-patient responses to nursing interventions and medical treatments
/.revision - Answer-care plan modifications suggested by the evaluation
/.what is a flow sheet? - Answer-Flow sheets present data from multiple encounters
allowing a comparison of findings over
a period of time.
/.focus charting (DAR) - Answer-Data (subjective and objective), action (nursing
intervention), response (evaluation), which is intended to make the patient and the
patient's concerns and strengths the focus of care
/.charting by exception (CBE) - Answer-focuses on documenting deviations
/.a goal that is not met is called - Answer-variance
/.discharge or referral summaries include some or all of the following - Answer-
description of patient's physical, mental, and emotional status at discharge or transfer
resolved health problems
unresolved continuing health problems and continuing care needs
treatments that are to be continued
current meds
restrictions
comfort level
functional/self-care abilities
patient education
support networks such as family
discharge destination
Latest Tests
discussion - Answer-an informal oral consideration of a subject by two or more
healthcare personnel to identify a problem or establish strategies
/.report - Answer-oral, written, or computer-based communication intended to convey
information to others
/.The process of making an entry on a patient record is called - Answer-recording,
charting, or documenting
/.clinical record - Answer-a formal, legal document that provides evidence of a patient's
care
/."The nurse has a duty to maintain confidentiality of all patient information" is said by
who? - Answer-The American Nurses Association (ANA) Code of Ethics
/.PHI is the abbreviation for - Answer-Protected Health Information
/.purposes of patient records include - Answer-communication, planning patient care,
auditing health agencies, research, education, reimbursement, legal documentation,
healthcare analysis
/.the traditional patient record is called - Answer-a source-oriented record
/.narrative charting consists of what? - Answer-Written notes which include routine care,
normal findings, and patient problems
/.examples of diagnostic reports are - Answer-laboratory reports, x-ray reports, CT scan
reports
/.examples of consultation reports are - Answer-physical therapy and respiratory
therapy
/.the abbreviation for POMR is - Answer-problem-oriented medical record
/.what is a POMR? - Answer-data is arranged according to the problems the patient has
rather than according to the source of the information
/.what are some advantages and disadvantages of a POMR? - Answer-advantages:
they encourage collaboration, and that the problem list in the front of the chart alerts
caregivers to the patient's needs, making it easier to track the status of each problem
, disadvantages: not all caregivers can use the charting format effectively, constant
vigilance is required to maintain an up-to-date problem list which can be inefficient
/.what is a database? - Answer-all information known about the patient
/.SOAP is an acronym for - Answer-subjective, objective, assessment, and planning
/.subjective data - Answer-what the person says about himself or herself during history
taking
/.objective data - Answer-information that is seen, heard, felt, or smelled by an observer;
signs
/.assessment - Answer-interpretation or conclusions drawn about the subjective and
objective data
/.interventions - Answer-actions taken to correct or manage a patient's problems
/.evaluation - Answer-patient responses to nursing interventions and medical treatments
/.revision - Answer-care plan modifications suggested by the evaluation
/.what is a flow sheet? - Answer-Flow sheets present data from multiple encounters
allowing a comparison of findings over
a period of time.
/.focus charting (DAR) - Answer-Data (subjective and objective), action (nursing
intervention), response (evaluation), which is intended to make the patient and the
patient's concerns and strengths the focus of care
/.charting by exception (CBE) - Answer-focuses on documenting deviations
/.a goal that is not met is called - Answer-variance
/.discharge or referral summaries include some or all of the following - Answer-
description of patient's physical, mental, and emotional status at discharge or transfer
resolved health problems
unresolved continuing health problems and continuing care needs
treatments that are to be continued
current meds
restrictions
comfort level
functional/self-care abilities
patient education
support networks such as family
discharge destination
