NUR 380 Exam
NUR 380 FUNDAMENTALS EXAM 2
QUESTIONS AND ANSWERS
what organization mandates computer databases to expedite accredidation process?
The Joint Commission
PURPOSES for MEDICAL RECORDS
a) communication
b) legal documentation
c) financial billing
d) education
e) research
f) auditing/monitoring
Purpose of reporting
provide continuity of care and enhance communication among all team members who
provide care to the same clients, thus promoting client safety
Elements of Documentation (4)
-Factual
-Accurate & Concise
-Complete & Current
-Organized
documentation formats
a) Flow Charts - record and show trends in vital signs, blood glucose levels, pain level
and other frequently performed assessments
b) Narrative Documentation - records information as a sequence of events
c) Charting by exception (CBE) - standardized forms that identify normal findings/values
and allows selective documentation of abnormal findings.
d) Problem oriented medical records (POMR) - consists of database, problem list, care
plan, and progress notes.( ex. SOAP, PIE, DAR)
NUR 380 Exam
, NUR 380 Exam
S.O.A.P
subjective, objective, assessment, plan
P.I.E.
problem, intervention, evaluation
D.A.R.
data, action, response
Reporting Formats
change-of-shift reports,
telephone reports,
telephone or verbal prescriptions,
transfer reports,
incident reports.
Health Informatics
Application of computer and information science in all basic and applied biomedical
sciences to facilitate the acquisition, processing, interpretation, optimal use, and
communication of health-related data.
Nursing informatics
the science of using computer information systems in the practice of nursing.
T.I.G.E.R.
Technology Informatics Guiding Education Reform
began 2006
identify information and knowledge managment best practices and effective technology
for nurses
CAI
Computer-assisted instruction
CPOE
Computerized Provider Order Entry
CPR
NUR 380 Exam
NUR 380 FUNDAMENTALS EXAM 2
QUESTIONS AND ANSWERS
what organization mandates computer databases to expedite accredidation process?
The Joint Commission
PURPOSES for MEDICAL RECORDS
a) communication
b) legal documentation
c) financial billing
d) education
e) research
f) auditing/monitoring
Purpose of reporting
provide continuity of care and enhance communication among all team members who
provide care to the same clients, thus promoting client safety
Elements of Documentation (4)
-Factual
-Accurate & Concise
-Complete & Current
-Organized
documentation formats
a) Flow Charts - record and show trends in vital signs, blood glucose levels, pain level
and other frequently performed assessments
b) Narrative Documentation - records information as a sequence of events
c) Charting by exception (CBE) - standardized forms that identify normal findings/values
and allows selective documentation of abnormal findings.
d) Problem oriented medical records (POMR) - consists of database, problem list, care
plan, and progress notes.( ex. SOAP, PIE, DAR)
NUR 380 Exam
, NUR 380 Exam
S.O.A.P
subjective, objective, assessment, plan
P.I.E.
problem, intervention, evaluation
D.A.R.
data, action, response
Reporting Formats
change-of-shift reports,
telephone reports,
telephone or verbal prescriptions,
transfer reports,
incident reports.
Health Informatics
Application of computer and information science in all basic and applied biomedical
sciences to facilitate the acquisition, processing, interpretation, optimal use, and
communication of health-related data.
Nursing informatics
the science of using computer information systems in the practice of nursing.
T.I.G.E.R.
Technology Informatics Guiding Education Reform
began 2006
identify information and knowledge managment best practices and effective technology
for nurses
CAI
Computer-assisted instruction
CPOE
Computerized Provider Order Entry
CPR
NUR 380 Exam
