NURS 6700: Exam 2 Questions With Complete Solutions
Identify purposes of a health care record.
interdisciplinary communication
legal record of care
justify billing/reimbursement
monitoring care
sources of research data
What are guidelines for electronic AND written documentation?
don't enter personal opinions
don't enter critical comments
correct errors promptly
record all facts
document discussions with providers
document only for yourself
avoid generalized phrases
date/time/sign each entry
use password
What are guidelines specific to written documentation?
use correction fluid instead of erasing
do not leave blank spaces or open lines
record legibly in black permanent ink
Identify ways to maintain confidentiality of records. (9)
,automatic sign-off
firewalls
restricted areas
privacy filters
motion detectors/alarms on mobile devices
access codes
frequent password changes
only allow personnel access in their own work area
track who accesses patient records
What are the 7 quality guidelines for documentation?
factual
accurate
timely
complete
organized
professional
confidential
What are 4 methods of documentation?
narrative
problem-oriented medical record
charting by exception
case management and use of critical pathways
What are 5 common record keeping forms?
,admission nursing history form
flow sheets and graphic records
patient care summary
standardized care plans
discharge summary forms
narrative documentation
information about the patient's health status, nursing
interventions, and treatments and the patient's
response to the care given
Use of a story-like format
Free text entry
Time consuming and repetitive
Can be good for complex situations
Problem-Oriented Medical Record (POMR) or Problem-Based
Charting
documentation system organized according to the person's
specific health problems; includes database, problem list, plan of
care, and progress notes
SOAPIER
, subjective, objective, assessment, plan, intervention, evaluation,
response
ex. S- "I just feel the urge to go but nothing comes out, it's been
this way since I started
taking this cholesterol medicine"
O- Abdomen slightly distended, hypoactive bowel sounds in all
4 quadrants, no stool in
4 days, taking Mevacor 10mg po daily
A- Constipation R/T side effects of medication
P- Increase po fluids to 800mL daily, increase dietary fiber,
consult physician about a
laxative or stool softener and about changing order for Mevacor
I- Placed water and juice at bedside, instructed to drink 8 az
fluid every hour, assisted
with menu selection of foods with dietary fiber, contacted doctor
about changing
medication, administered 100mg Colace po @0900
E- I'm drinking all this water and eating prunes and I still haven't
had a bowel
movement"
R-Administer fleets enema as ordered by physician
charting by exception
Document only significant or abnormal findings.
Do not document normal findings over and over again (normal
Identify purposes of a health care record.
interdisciplinary communication
legal record of care
justify billing/reimbursement
monitoring care
sources of research data
What are guidelines for electronic AND written documentation?
don't enter personal opinions
don't enter critical comments
correct errors promptly
record all facts
document discussions with providers
document only for yourself
avoid generalized phrases
date/time/sign each entry
use password
What are guidelines specific to written documentation?
use correction fluid instead of erasing
do not leave blank spaces or open lines
record legibly in black permanent ink
Identify ways to maintain confidentiality of records. (9)
,automatic sign-off
firewalls
restricted areas
privacy filters
motion detectors/alarms on mobile devices
access codes
frequent password changes
only allow personnel access in their own work area
track who accesses patient records
What are the 7 quality guidelines for documentation?
factual
accurate
timely
complete
organized
professional
confidential
What are 4 methods of documentation?
narrative
problem-oriented medical record
charting by exception
case management and use of critical pathways
What are 5 common record keeping forms?
,admission nursing history form
flow sheets and graphic records
patient care summary
standardized care plans
discharge summary forms
narrative documentation
information about the patient's health status, nursing
interventions, and treatments and the patient's
response to the care given
Use of a story-like format
Free text entry
Time consuming and repetitive
Can be good for complex situations
Problem-Oriented Medical Record (POMR) or Problem-Based
Charting
documentation system organized according to the person's
specific health problems; includes database, problem list, plan of
care, and progress notes
SOAPIER
, subjective, objective, assessment, plan, intervention, evaluation,
response
ex. S- "I just feel the urge to go but nothing comes out, it's been
this way since I started
taking this cholesterol medicine"
O- Abdomen slightly distended, hypoactive bowel sounds in all
4 quadrants, no stool in
4 days, taking Mevacor 10mg po daily
A- Constipation R/T side effects of medication
P- Increase po fluids to 800mL daily, increase dietary fiber,
consult physician about a
laxative or stool softener and about changing order for Mevacor
I- Placed water and juice at bedside, instructed to drink 8 az
fluid every hour, assisted
with menu selection of foods with dietary fiber, contacted doctor
about changing
medication, administered 100mg Colace po @0900
E- I'm drinking all this water and eating prunes and I still haven't
had a bowel
movement"
R-Administer fleets enema as ordered by physician
charting by exception
Document only significant or abnormal findings.
Do not document normal findings over and over again (normal
