Comprehensive Review Of Nursing Documentation
And The Nursing Process – Questions With
Reliable Solutions
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Terms in this set (78)
What are the five basic purposes of Documented communication, permanent record for
patient records? accountability, legal record of care, teaching, and
research/data collection.
What is data clustering in nursing? Organizing related data to assist in determining
patient problems.
What do diagnosis-related groups Patients by age, diagnosis, and surgical procedure to
(DRGs) classify? predict hospital resource use.
What is the primary use of the patient To communicate care between providers, document
record (chart)? assessments/interventions, provide legal evidence,
support billing, and track patient progress.
What is the purpose of Electronic To make charting faster, standardized, and
Health Records (EHRs)? consistent, reducing errors and making
documentation easier for nurses.
What does ISBAR stand for? Identification, Situation, Background, Assessment,
Recommendation.
What is the additional 'R' in ISBARR? Read back, which is used for clarification during
communication.
What is the significance of quality and It is extremely important for effective communication
accuracy in nursing documentation? and patient care.
, What does 'SOAPE' stand for in Subjective, Objective, Assessment, Plan, Evaluation.
nursing documentation?
What is a traditional chart in nursing? A paper-based chart organized into separate
sections for various patient care aspects.
What is the purpose of incident To document unexpected events for quality
reports? improvement, not placed in the patient's chart.
What is the role of the nurse in the The registered nurse (RN) is responsible for the initial
admission nursing history? admission nursing history, physical assessment, and
development of the care plan.
What is the proper way to correct an Draw a single line through the error, write 'error'
error in a patient's chart? above it, and sign your name or initials.
What are the key components of They coordinate medical and nursing interventions
clinical pathways? and monitor patient progress.
What does the Omnibus Budget Standards for resident assessment, individualized
Reconciliation Act (OBRA) of 1987 care plans, and qualifications for health care
regulate? providers.
What is the importance of Nurses should not read a patient's medical record
confidentiality in nursing unless there is a clinical reason to do so.
documentation?
What is the nursing process? A framework to organize individualized nursing care
with a problem-solving emphasis.
What are the six phases of the nursing Assessment, Diagnosis, Outcome Identification,
process? Planning, Implementation, Evaluation.
What is the focus of the assessment To collect, organize, and validate the patient's
phase in the nursing process? subjective and objective data.
What is the goal of the diagnosis To analyze data to identify actual or potential patient
phase in the nursing process? problems that nurses can address.
And The Nursing Process – Questions With
Reliable Solutions
Save
Terms in this set (78)
What are the five basic purposes of Documented communication, permanent record for
patient records? accountability, legal record of care, teaching, and
research/data collection.
What is data clustering in nursing? Organizing related data to assist in determining
patient problems.
What do diagnosis-related groups Patients by age, diagnosis, and surgical procedure to
(DRGs) classify? predict hospital resource use.
What is the primary use of the patient To communicate care between providers, document
record (chart)? assessments/interventions, provide legal evidence,
support billing, and track patient progress.
What is the purpose of Electronic To make charting faster, standardized, and
Health Records (EHRs)? consistent, reducing errors and making
documentation easier for nurses.
What does ISBAR stand for? Identification, Situation, Background, Assessment,
Recommendation.
What is the additional 'R' in ISBARR? Read back, which is used for clarification during
communication.
What is the significance of quality and It is extremely important for effective communication
accuracy in nursing documentation? and patient care.
, What does 'SOAPE' stand for in Subjective, Objective, Assessment, Plan, Evaluation.
nursing documentation?
What is a traditional chart in nursing? A paper-based chart organized into separate
sections for various patient care aspects.
What is the purpose of incident To document unexpected events for quality
reports? improvement, not placed in the patient's chart.
What is the role of the nurse in the The registered nurse (RN) is responsible for the initial
admission nursing history? admission nursing history, physical assessment, and
development of the care plan.
What is the proper way to correct an Draw a single line through the error, write 'error'
error in a patient's chart? above it, and sign your name or initials.
What are the key components of They coordinate medical and nursing interventions
clinical pathways? and monitor patient progress.
What does the Omnibus Budget Standards for resident assessment, individualized
Reconciliation Act (OBRA) of 1987 care plans, and qualifications for health care
regulate? providers.
What is the importance of Nurses should not read a patient's medical record
confidentiality in nursing unless there is a clinical reason to do so.
documentation?
What is the nursing process? A framework to organize individualized nursing care
with a problem-solving emphasis.
What are the six phases of the nursing Assessment, Diagnosis, Outcome Identification,
process? Planning, Implementation, Evaluation.
What is the focus of the assessment To collect, organize, and validate the patient's
phase in the nursing process? subjective and objective data.
What is the goal of the diagnosis To analyze data to identify actual or potential patient
phase in the nursing process? problems that nurses can address.
