Adult Nursing 1 Exam 1 Study guide
What information is confidential in a healthcare setting? - ANS All information about patients
regardless of if it is handwritten, saved on a computer, or spoken out loud.
Give a few examples of breaches of confidentiality - ANS -Discussing patient information where
it can be overheard
-Leaving patient medical information in a public area
-Leaving patient information up on a computer that is unattended
-Sharing or exposing passwords
-Improperly accessing, releasing or reviewing a patient's record out of curiosity or concern
-Improperly accessing, releasing, or reviewing any patient information regardless of your
relationship with the patient
Information/Documentation should be clear, complete, concise, accurate, and factual. What are
other important aspects of Documentation? - ANS -Documentation should reflect the nursing
process and your professional responsibilities
-Avoid generalizations in documentation
-Note problems/situations in chronological order, add/update and delete problems as needed
-Record precautions or preventative measures used
-Avoid stereotypes
-Document the nursing response to questionable orders or treatment
PIE Charting - ANS method of recording the client's progress under the headings of problem,
intervention, and evaluation
Focus charting - ANS Brings the focus of care back to the patient and the patient's concerns.
Narrative portion uses DAR (Data, Action, Response) format
Charting by exception - ANS only documenting abnormal findings/issues
-everything is normal except for...
SOAP format - ANS method of charting narrative progress notes; organizes data according to
subjective information (S), objective information (O), assessment (A), and plan (P)
Narrative notes - ANS address routine care, normal findings, and patient problems identified in
the plan of care
ISBAR - ANS Introduction
Situation
Background
Assessment
, Recommendation
SOAPIE - ANS subjective
objective
assessment
plan
intervention
evaluation
Change of shift report - ANS Includes:
-Basic information about each patient (name, room, bed, diagnosis, consulting physicians)
-Current appraisal of each patient's health status
-Current orders
-Abnormal occurrences during shift
-Any unfilled orders that need to be continued onto next shift
-Patient's questions, concerns, needs
-Reports on transfers/discharge
Bedside report - ANS Oncoming and outgoing nurse seeing the patient together, reviewing
medication records and the HCP's and nursing orders, and establishing patient goals for the
shift.
Problem oriented medical record - ANS Organized according to patient's problems rather than
sources of information. Includes defined database, problem list, care plans, and progress notes.
Progress notes - ANS documentation of the progress a patient is making towards achieving
expected outcomes
Occurrence/variance charting - ANS documentation when a patient fails to meet an expected
outcome
include the unexpected event, the cause of the event, actions taken in response to the event,
and discharge planning, when appropriate; typically used for variances that affect quality, cost,
or length of stay
Purposes of patient records - ANS -Communication
-Diagnostic and therapeutic orders
-Care planning
-Quality process and performance improvement
-Research; decision analysis
-Education
-Credentialing, regulation, and legislation
-Reimbursement
-Legal and historical documentation
What information is confidential in a healthcare setting? - ANS All information about patients
regardless of if it is handwritten, saved on a computer, or spoken out loud.
Give a few examples of breaches of confidentiality - ANS -Discussing patient information where
it can be overheard
-Leaving patient medical information in a public area
-Leaving patient information up on a computer that is unattended
-Sharing or exposing passwords
-Improperly accessing, releasing or reviewing a patient's record out of curiosity or concern
-Improperly accessing, releasing, or reviewing any patient information regardless of your
relationship with the patient
Information/Documentation should be clear, complete, concise, accurate, and factual. What are
other important aspects of Documentation? - ANS -Documentation should reflect the nursing
process and your professional responsibilities
-Avoid generalizations in documentation
-Note problems/situations in chronological order, add/update and delete problems as needed
-Record precautions or preventative measures used
-Avoid stereotypes
-Document the nursing response to questionable orders or treatment
PIE Charting - ANS method of recording the client's progress under the headings of problem,
intervention, and evaluation
Focus charting - ANS Brings the focus of care back to the patient and the patient's concerns.
Narrative portion uses DAR (Data, Action, Response) format
Charting by exception - ANS only documenting abnormal findings/issues
-everything is normal except for...
SOAP format - ANS method of charting narrative progress notes; organizes data according to
subjective information (S), objective information (O), assessment (A), and plan (P)
Narrative notes - ANS address routine care, normal findings, and patient problems identified in
the plan of care
ISBAR - ANS Introduction
Situation
Background
Assessment
, Recommendation
SOAPIE - ANS subjective
objective
assessment
plan
intervention
evaluation
Change of shift report - ANS Includes:
-Basic information about each patient (name, room, bed, diagnosis, consulting physicians)
-Current appraisal of each patient's health status
-Current orders
-Abnormal occurrences during shift
-Any unfilled orders that need to be continued onto next shift
-Patient's questions, concerns, needs
-Reports on transfers/discharge
Bedside report - ANS Oncoming and outgoing nurse seeing the patient together, reviewing
medication records and the HCP's and nursing orders, and establishing patient goals for the
shift.
Problem oriented medical record - ANS Organized according to patient's problems rather than
sources of information. Includes defined database, problem list, care plans, and progress notes.
Progress notes - ANS documentation of the progress a patient is making towards achieving
expected outcomes
Occurrence/variance charting - ANS documentation when a patient fails to meet an expected
outcome
include the unexpected event, the cause of the event, actions taken in response to the event,
and discharge planning, when appropriate; typically used for variances that affect quality, cost,
or length of stay
Purposes of patient records - ANS -Communication
-Diagnostic and therapeutic orders
-Care planning
-Quality process and performance improvement
-Research; decision analysis
-Education
-Credentialing, regulation, and legislation
-Reimbursement
-Legal and historical documentation
