NUR155 EXAM (1)ONE STUDY GUIDE Exam One Study Guide With Complete Solutions

NUR155 EXAM (1)ONE STUDY GUIDE Exam One Study Guide With Complete Solutions Documenting and Reporting: Chart For everyone to see that is caring for patient, only look at charts of patients you need to know about. • can be formal or informal • oral written or computerized • chart is a legal record Legal considerations: • chart is legally protected • organization owns • patient has rights to chart • restricted access HIPPA: • Health insurance portability and accountability act 1996;amended 2003 • Duty is to protect PHI- Protected health information Computerized records: • Cerner • Epic • Meditech Purpose of records (DRG) diagnosed related group • Communication, planning client care, research • Auditing, reimbursement, legal documentation • Education, health care analysis Documentation Systems • Source oriented record: traditional, each department or individual has their own section • Narrative: component of source oriented, no right or wrong order; chronological used Problem Oriented medical record- POR • 4 basic components: • Database: known when pt 1st enters health care facility, nursing assessment, primary care history, social & family data, baseline physical exam & diagnostic test. • Problem list: derived from database. Caregivers contribute, physiological, psychological, social, cultural, spiritual, development, and environmental needs. Medical problems, diagnoses, surgical procedures, symptoms; nurse diagnoses. (ex impaired mobility, urinary incontinence). • Plan of Care- Initial list of orders or plan of care. • Progress notes- chart entry’s made by ALL Health care professionals involved in patients care. SOAP or SOAPIER- Subjective- obtained from client, Objective-information measured or observed (vital signs, lab, x-ray). Assessment- conclusions drawn subjective and objective from data (clients condition and level of progress). Plan- plan designed to resolve stated problem. I- intervention, E- evaluation, R- revision. PIE- Problems Interventions Evaluation • Consists or patient flow sheets and progress notes DAR- Data Action Response • Focus charting- intended to make patient concerns and strengths the focus of care CBE- Charting by Exception • Only abnormal or significant findings, exceptions to the norms recorded. 3 key elements: Flow sheets (vitals, head and face assessment) Standards of care- unconscious patient oral care q4h. Beside access chart forms- all flow sheets kept at patients bedside for immediate recording. *Guidelines for recording • Date/ time • Legibility • Permanence-Ink • Accepted terminology • Signature, Accuracy and completeness *SBAR • S- situation- state your name, unit, patient name, briefly state problem • B- background- admission diagnoses, medical history, summary of tx to date, code status • A- assessment- vital signs, pain scale, change from prior assessment • R- recommendation- what you would like done, ask provider wants to order test or meds, if they want to be notified for any reason, no improvement when you should call. • I- introduction Health Promotion vs Protection Holism- emphasizes on whole person understand how one are relates to another, relationship to external environment and others. (appetite, rest, energy level, activities, family, relationship) Promotion • No disease process- a way of thinking • Positive approach to wellness Protection • Already sick • Stop potential health occurrence or insults to health Homeostasis • Self regulating- body monitor-healthy person • Compensatory- counter balancing abnormal conditions for person • Feedback systems- Negative; inhibits change Positive; stimulates change. • Input- material enters system (food) Throughput- transformation(digested food) Output- information given out ( energy, nutrients, urine, feces) MASLOW- needs theorist- (5 levels) Kalish added 6th to Maslows ( Stimulation- under physiological – sex, manipulation, exploration, activity)