NURS 371.docx

NURS 371 EXAM 2024/2025 WITH 100% CORRECT
ANSWERS




Documentation is - correct answer The written or electronic legal record of all pertinent interactions with the
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patient assessing diagnosing planning implementing and evaluating
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Characteristic of effective documentation - correct answer Consistent with professional and agency
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standerds, complete , accurate, concise, factual, organized and timely, legally prudent, confidential
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What is confidential? - correct answer All information about patients written on paper spoken aloud saved on
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commuter (Name, address, phone, fax social security, reason the person is sick, assessments and treatments
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patient receives, information about past health conditions)
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A nurse who fails to log off a commuter after documenting patient care has breached patient confidentiallity
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true or false - correct answer True
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A patient has the right to obtain review and revise the patient information in his or her health record True or
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false - correct answer False
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,Records included: - correct answer client identification and demogrphic data, informed consent for treatment
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and procedures, admission nursing history, nursing diagnoses or problems, nursing or multidiscriplinary care
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plan includes respiratory disease, records of nursing care treatment and evaluation, medical history, medical
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diagnosis, therapy orders, medical and health discipline progress notes, reports of physical examinations,
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reports of diagnostic studies, summary of operative procedures, discharge plan and summary
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Purpose of patient records - correct answer Communication with other healthcare professionals, records of
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diagnostic and therapeutic orders, care plannning, quality process and performance improvement, research,
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decision analysis, education, credentialing regulation and legislation, legal and historical documentation,
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reimbursement, facilitate patient care, serve as a financial and legal record, help in clinical research, support b b b b b b b b b b b b b b b b




decision analysis b




Guidelines for receiving verbal orders in an emergency - correct answer record the orders in patients medical
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records, read back the order to verify accuracy, date and not the time orders were issued in emergency, record
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VO, the name of the physician or nurse practitioner followed by nurses name and title, the registered
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professional nurse nurse must see that the orders are transcribed according to procedure
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Terminology used: - correct answer Medical terminology used to facilitate communication, breakdown
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medical terminology into the three parts prefix root suffix
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Terminology Abbreviation notes - correct answer Keep to standard abbreviation different areas or specialties
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vary, know approved abbreviation for specific agency
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Documentation Essentials Legal document: What you need: - correct answer Black ink, contain facts and be b b b b b b b b b b b b b b b b




accurate, legible, brief/concise, exact time (may be military time), logical by time and content,
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Errors/Omissions, no blank spaces, signature b b b b




Good assessors are usuallly good charters why? - correct answer Assessing from head to toe paining a good
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picture should chart what you did and saw
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Charting: - correct answer Takes time and practice, practice, proactive, you will always be perfecting the skill
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When to chart? - correct answer Admission, assuming care, transferring a patient, discharging a patient
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, Types of entries: - correct answer Newly admitted patient, opening notes for shift, interval notes(when
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something has changed), anything abnormal, any change, test, lab, doctor visit, dietitian show orders carried
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out, transfer discharge
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Documentation essentials: - correct answer Patient teaching, entries should be objective avoid good, bad,
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seems like, do symptom analysis on complaints/pain, Entries must reflect patient needs if you find something
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wrong you must chart what you did and how your patient responded, dressing should not location
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attachments drainage not skin condition if removed, tubes state type placement infusion site condition
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drainage suction, Mar available for routine meds PRN are entered in narrative notes with assessment
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intervention and response note meds not given (when patient complains of pain state nurse notified ,
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Psychosocial-LOC and safety, ADL-flow sheet/transfer needs, Jewelry- describe (gold-yellow) where sent and b b b b b b b b b b b b




who recieved, spiritual care- not expression of grief/anger symbols/rituals, sins of distress sources of hope,
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safety:side rails ambulation call light restraints teaching about safety incident form is fall, elderly:ADL mobility
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safety mental status affective behavior
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Methods of documentation: source oriented - correct answer Separate division for each discipline, may be
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narrative



Methods of documentation problem oriented - correct answer data base, problem list, plans, progress
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Documentation formats-problem oriented: - correct answer SOAP: subjective data, objective data, b b b b b b b b b b b




assessment, plan b




APIE: assessment, problems, interventions, evaluations
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Focus:Data, action, response b b




charting by exception b b




case management model
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collaborative pathways b




occurrence charting b




computerized records b




Documentation formats: - correct answer 24 hour assessment -note abnormal findings in narrative b b b b b b b b b b b b




kardex plan of care/needs list
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pathways b