AND ANSWERS
What are the purposes of patient charts? - ANS 1. documented communication
2.permanent record for accountability
3. legal record of care
4. teaching
5. research and data collection
What do patient charts provide? - ANS Concise, accurate, and permanent record of past and
current medical and nursing problems, plans for care, care given, and the patient's responses to
various treatments of care
What is focus charting? - ANS modified list of patient problem statements that are used as
an index for nursing documentation.
uses the nursing process and the more positive concept of the patients needs rather than
medical diagnoses and problems
POMR - ANS Problem Oriented Medical Record
What is POMR charting? - ANS organized according to scientific problem solving system or
method.
The principal sections are database, problem list, care plan, and progress notes
What is DARE used for? - ANS focus charting (Data, Action, Response, Education)
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, Why are outside agencies in Long Term healthcare documentation important? - ANS play an
instrumental role in determining standards and policies for documentation
What is OBRA? - ANS Omnibus Budget Reconciliation Act of 1987 instituted significant
Medicare and Medicaid requirements for long-term care provision and documentation.
Are minimum data sets and regulated standards for resident assessments, individualized care
plans, and qualifications for health care providers
Why is confidentiality important in patient records? - ANS The Health Insurance Portability
and Accountability Act (HIPAA) affords certain protections to persons covered by health care
plans, including continuity of coverage when changing jobs, standards for electronic health care
transactions, and primary safeguards for the privacy of individually identifiable patient
information
What is the implementation of the nursing process by the RN and LVN? - ANS -ASSESS: RN is
responsible for initial assessment while LVN assists with ongoing assessments
-DIAGNOSIS: RN identifies appropriate nursing diagnosis (patient problem) with assistance from
LVN
-PLAN/OUTCOME IDENTIFIED: RN develops goals/expected outcomes directly associated with
nursing diagnosis and LVN can also help identify these
-IMPLEMENT: RN and LVN implement proposed plan
-EVALUATE: RN and LVN perform ongoing assessments and RN determines whether
needs/goals have been met
What is the differentiation of medical and patient problems? - ANS patient problem
statements address human responses to health problems and life processes
medical problem is type of diagnosis and may not change but patient problem statements may
change or resolve as care is provided
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