LVN Unitek Quiz #3 || Solved Correctly.
What are the purposes of patient charts? correct answers 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? correct answers 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? correct answers 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 correct answers Problem Oriented Medical Record
What is POMR charting? correct answers 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? correct answers focus charting (Data, Action, Response, Education)
Why are outside agencies in Long Term healthcare documentation important? correct answers
play an instrumental role in determining standards and policies for documentation
, What is OBRA? correct answers 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? correct answers 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? correct answers -
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? correct answers 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
Why is goal identification important? correct answers -nurse and patient collaboratively develop
expected outcomes for the established patient problem. A goal statement is created and provides
a description of the specific, measurable behavior that patient will be able to exhibit in given
time frame after the interventions
What are the purposes of patient charts? correct answers 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? correct answers 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? correct answers 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 correct answers Problem Oriented Medical Record
What is POMR charting? correct answers 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? correct answers focus charting (Data, Action, Response, Education)
Why are outside agencies in Long Term healthcare documentation important? correct answers
play an instrumental role in determining standards and policies for documentation
, What is OBRA? correct answers 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? correct answers 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? correct answers -
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? correct answers 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
Why is goal identification important? correct answers -nurse and patient collaboratively develop
expected outcomes for the established patient problem. A goal statement is created and provides
a description of the specific, measurable behavior that patient will be able to exhibit in given
time frame after the interventions
