NURS 215- Exam 2 Questions And Accurate Answers
What is the sequence of documentation?
In chronological order
3 choices
- There are separate sections of the chart in which disciplines document
- Contains multiple sections (e.g admission, advanced directive, H&P, diagnostic,
graphic, nurses' notes, progress notes, lab, rehab notes, DC plan, etc)
- Data scattered; may lead to fragmentation
Source-oriented program
2 choices
- Organized around client problems
- Database, problem list, plan of care, progress notes
- Stimulates much more teamwork
Problem-oriented system
2 multiple choice
suicides
- Only the abnormal findings are documented
- Utilizes preprinted flow sheets
- Takes away the minutes spent charting the information
- May lead to the omission of documenting information and omission of care because it
,was assumed done when it wasn't
*Assumes that all standard have been met and the patient responded normally, unless a
separate entry is made(an exception)*
Charting by exception
2 multiple choice options
What writing utensil should you use for handwritten notes?
Black pen
3 multiple choice options
How do you fix incorrect handwritten documentation?
Draw a line through the incorrect documentation, write"mistaken entry," and initial it
3 multiple choice options
,- Can use with source or problem oriented system
- "Story" of care in chronological format
- Tracks the client's changing status
- Document accurately and objectively, using nonjudgmental language
- Avoid vague, subjective words
- Avoid documenting what someone else said, heard, felt or smelled.
Narrative documentation
3 multiple choice options
xxxxx
xxxxx
xxxxx
Problem: use data from assessment to identify appropriate nursing diagnoses
Interventions: nursing actions taken
Evaluation: client's response
*Used only in problem-oriented charting
*Establishes an ongoing plan of care
PIE
3 multiple choice options
xxxxx
, xxxxx
xxxxx
Subjective data
- Objective data
- Assessment: conclusions drawn from subjective and objective data, usually client
problems or nursing diagnoses
- Plan: short-term and long-term goals and strategies used to relieve the problem
- Intervention: actions taken
- Evaluation: analysis of effectiveness of interventions
- Revision: changes made to original plan
SOAP/SOAPIE/SOAPIER
3 multiple choice options
DAR:
- Data: subjective and objective, Labs, tests
- Action: interventions performed, meds, calls to provider
- Response: describes client's response to interventions
Focus charting
3 choices
Summary of individual clients
Usually stored in a moveable file or in one location
Kardex / Client Care Summary
3 choices
Chart of baseline information from which to track change
What is the sequence of documentation?
In chronological order
3 choices
- There are separate sections of the chart in which disciplines document
- Contains multiple sections (e.g admission, advanced directive, H&P, diagnostic,
graphic, nurses' notes, progress notes, lab, rehab notes, DC plan, etc)
- Data scattered; may lead to fragmentation
Source-oriented program
2 choices
- Organized around client problems
- Database, problem list, plan of care, progress notes
- Stimulates much more teamwork
Problem-oriented system
2 multiple choice
suicides
- Only the abnormal findings are documented
- Utilizes preprinted flow sheets
- Takes away the minutes spent charting the information
- May lead to the omission of documenting information and omission of care because it
,was assumed done when it wasn't
*Assumes that all standard have been met and the patient responded normally, unless a
separate entry is made(an exception)*
Charting by exception
2 multiple choice options
What writing utensil should you use for handwritten notes?
Black pen
3 multiple choice options
How do you fix incorrect handwritten documentation?
Draw a line through the incorrect documentation, write"mistaken entry," and initial it
3 multiple choice options
,- Can use with source or problem oriented system
- "Story" of care in chronological format
- Tracks the client's changing status
- Document accurately and objectively, using nonjudgmental language
- Avoid vague, subjective words
- Avoid documenting what someone else said, heard, felt or smelled.
Narrative documentation
3 multiple choice options
xxxxx
xxxxx
xxxxx
Problem: use data from assessment to identify appropriate nursing diagnoses
Interventions: nursing actions taken
Evaluation: client's response
*Used only in problem-oriented charting
*Establishes an ongoing plan of care
PIE
3 multiple choice options
xxxxx
, xxxxx
xxxxx
Subjective data
- Objective data
- Assessment: conclusions drawn from subjective and objective data, usually client
problems or nursing diagnoses
- Plan: short-term and long-term goals and strategies used to relieve the problem
- Intervention: actions taken
- Evaluation: analysis of effectiveness of interventions
- Revision: changes made to original plan
SOAP/SOAPIE/SOAPIER
3 multiple choice options
DAR:
- Data: subjective and objective, Labs, tests
- Action: interventions performed, meds, calls to provider
- Response: describes client's response to interventions
Focus charting
3 choices
Summary of individual clients
Usually stored in a moveable file or in one location
Kardex / Client Care Summary
3 choices
Chart of baseline information from which to track change
