NURS 230: exam 2 questions and answers A+
updated already passed
1. healthcare
-written or electronically generated information that describes the patient,
docu-
the patient's health, and the care and services provided, including the
mentation
dates of care
-purpose: facilitate the flow of information that supports the continuity,
quality, and safe patient care
-communication of information should be clear, concise, and accurate
2. principles of
doc- must be complete and legible and include information regarding
umentation assessments, diagnostics, diagnosis, plan of care, progress, dates, and
identity of documenters
3. medical record - comprehensive legal document containing patient information
-serves as a communication tool between member of the healthcare team
-must be complete, accurate, timely, accessible, and authentic (truthful)
-types:
-- written
-- electronic
4. electronic -improves the quality of nursing documentation which enhances
health patient safety and communication with other providers
records
-types:
-- EMR
-- EHR
-- eMAR
-- CPOE
5. EMR - electronic medical record
-records of one episode of care
6. EHR - electronic health record
-comprehensive, longitudinal record of health
,NURS 230: exam 2 questions and answers A+
updated already passed
-includes all episodes of care from all healthcare settings
-documentation
-- must have a level of computer competency
-- must always have computer support and maintenance available
,NURS 230: exam 2 questions and answers A+
updated already passed
-- have computers readily available
-- protect patient information
-- access is gained by passwords and verification codes that are NEVER
shared
7. eMAR - electronic medication administration record
-bar-coded medication administration
8. CPOE - computerized provider order entry
-order entry system for providers
9. critical aspects sum- mary
of
documentatio
n
10. documentatio
n formats
11. admission
sum- mary
12. discharge
,NURS 230: exam 2 questions and answers A+
updated already passed
-use standardized terminology -- includes all the abnormals
-- common language facilitates -flow sheets
communication and increases -- used to document routine care and observations that are recorded on a
patient safety regular basis (vital signs, medications, i&o measurements)
-should no include do-not-use
abbreviations includes the patient's history, a medication reconciliation, and an initial
-must be clear, concise, assess- ment that addresses the patient's problems, including
complete, relevant, and identification of needs pertinent to discharge planning and
objective
formulation of a plan of care according to those needs
-narrative charting
-addresses the patient's hospital course and plans for follow-up
-- chronological on a shift-by-
-documents the patient's status at discharge
shift basis
-includes informations on medication and treatment, discharge
-- time consuming and lengthy
placement, pa- tient education, follow-up appointments, and referrals
-charting by exception
updated already passed
1. healthcare
-written or electronically generated information that describes the patient,
docu-
the patient's health, and the care and services provided, including the
mentation
dates of care
-purpose: facilitate the flow of information that supports the continuity,
quality, and safe patient care
-communication of information should be clear, concise, and accurate
2. principles of
doc- must be complete and legible and include information regarding
umentation assessments, diagnostics, diagnosis, plan of care, progress, dates, and
identity of documenters
3. medical record - comprehensive legal document containing patient information
-serves as a communication tool between member of the healthcare team
-must be complete, accurate, timely, accessible, and authentic (truthful)
-types:
-- written
-- electronic
4. electronic -improves the quality of nursing documentation which enhances
health patient safety and communication with other providers
records
-types:
-- EMR
-- EHR
-- eMAR
-- CPOE
5. EMR - electronic medical record
-records of one episode of care
6. EHR - electronic health record
-comprehensive, longitudinal record of health
,NURS 230: exam 2 questions and answers A+
updated already passed
-includes all episodes of care from all healthcare settings
-documentation
-- must have a level of computer competency
-- must always have computer support and maintenance available
,NURS 230: exam 2 questions and answers A+
updated already passed
-- have computers readily available
-- protect patient information
-- access is gained by passwords and verification codes that are NEVER
shared
7. eMAR - electronic medication administration record
-bar-coded medication administration
8. CPOE - computerized provider order entry
-order entry system for providers
9. critical aspects sum- mary
of
documentatio
n
10. documentatio
n formats
11. admission
sum- mary
12. discharge
,NURS 230: exam 2 questions and answers A+
updated already passed
-use standardized terminology -- includes all the abnormals
-- common language facilitates -flow sheets
communication and increases -- used to document routine care and observations that are recorded on a
patient safety regular basis (vital signs, medications, i&o measurements)
-should no include do-not-use
abbreviations includes the patient's history, a medication reconciliation, and an initial
-must be clear, concise, assess- ment that addresses the patient's problems, including
complete, relevant, and identification of needs pertinent to discharge planning and
objective
formulation of a plan of care according to those needs
-narrative charting
-addresses the patient's hospital course and plans for follow-up
-- chronological on a shift-by-
-documents the patient's status at discharge
shift basis
-includes informations on medication and treatment, discharge
-- time consuming and lengthy
placement, pa- tient education, follow-up appointments, and referrals
-charting by exception
