COMPREHENSIVE NURS 6050 AGENDA
COMPARISON GRID & FACT QUESTIONS
AND ANSWERS GRADED A+
◉ 5 areas that should be covered in documentation. Answer:
1. Physical
2. emotional
3. psychosocial
4. social
5. spiritual
◉ DRG's Answer: Diagnosis-related groups.
◉ What are DRG's Answer: System that classifies patients by age,
diagnosis and surgical procedure, using 300 different categories to
predict the use of hospital resources, including length of stay.
◉ Nursing Notes Answer: The form on the patient's chart on which
nurses record their observations, the care given and the patient's
responses.
◉ 4 most common forms of inadequate documentation. Answer:
, 1. Not charting the correct time when events occurred.
2. Failing to record verbal orders or failing to have them signed.
3. Charting, actions in advance to save time.
4. Documenting incorrect data.
◉ Traditional(block) chart Answer: Divided into blocks/sections. i.e.
- admission sheets, physician's orders, progress note, H & P
examination data, nurse's admission information, care plan, nursing
notes, graphs, laboratory and x-ray examination reports.
◉ Narrative Charting Answer: Recording of patient care in narrative
form.
◉ Problem-Oriented Medical Record (POMR) Answer: Organized
according to the scientific problem-solving system or method.
Principal sections are database, problem list, care plan and progress
notes.
◉ S.O.A.P.I.E.R. Answer:
S - Subjective information is what the patient states or feels, only the
patient can provide this information.
O - Objective information is what the nurse can measure or factually
describe.
A - Assessment refers to an analysis or potential diagnosis of the
cause of the patient's problem or need.
COMPARISON GRID & FACT QUESTIONS
AND ANSWERS GRADED A+
◉ 5 areas that should be covered in documentation. Answer:
1. Physical
2. emotional
3. psychosocial
4. social
5. spiritual
◉ DRG's Answer: Diagnosis-related groups.
◉ What are DRG's Answer: System that classifies patients by age,
diagnosis and surgical procedure, using 300 different categories to
predict the use of hospital resources, including length of stay.
◉ Nursing Notes Answer: The form on the patient's chart on which
nurses record their observations, the care given and the patient's
responses.
◉ 4 most common forms of inadequate documentation. Answer:
, 1. Not charting the correct time when events occurred.
2. Failing to record verbal orders or failing to have them signed.
3. Charting, actions in advance to save time.
4. Documenting incorrect data.
◉ Traditional(block) chart Answer: Divided into blocks/sections. i.e.
- admission sheets, physician's orders, progress note, H & P
examination data, nurse's admission information, care plan, nursing
notes, graphs, laboratory and x-ray examination reports.
◉ Narrative Charting Answer: Recording of patient care in narrative
form.
◉ Problem-Oriented Medical Record (POMR) Answer: Organized
according to the scientific problem-solving system or method.
Principal sections are database, problem list, care plan and progress
notes.
◉ S.O.A.P.I.E.R. Answer:
S - Subjective information is what the patient states or feels, only the
patient can provide this information.
O - Objective information is what the nurse can measure or factually
describe.
A - Assessment refers to an analysis or potential diagnosis of the
cause of the patient's problem or need.
