Nurs 371 questions with correct answers
Documentation is Correct Answer-The written or electronic legal record
of all pertinent interactions with the patient assessing diagnosing
planning implementing and evaluating
Characteristic of effective documentation Correct Answer-Consistent
with professional and agency standerds, complete , accurate, concise,
factual, organized and timely, legally prudent, confidential
What is confidential? Correct Answer-All information about patients
written on paper spoken aloud saved on commuter (Name, address,
phone, fax social security, reason the person is sick, assessments and
treatments patient receives, information about past health conditions)
A nurse who fails to log off a commuter after documenting patient care
has breached patient confidentiallity true or false Correct Answer-True
A patient has the right to obtain review and revise the patient
information in his or her health record True or false Correct Answer-
False
Records included: Correct Answer-client identification and demogrphic
data, informed consent for treatment and procedures, admission nursing
history, nursing diagnoses or problems, nursing or multidiscriplinary
care plan includes respiratory disease, records of nursing care treatment
and evaluation, medical history, medical diagnosis, therapy orders,
medical and health discipline progress notes, reports of physical
,examinations, reports of diagnostic studies, summary of operative
procedures, discharge plan and summary
Purpose of patient records Correct Answer-Communication with other
healthcare professionals, records of diagnostic and therapeutic orders,
care plannning, quality process and performance improvement, research,
decision analysis, education, credentialing regulation and legislation,
legal and historical documentation, reimbursement, facilitate patient
care, serve as a financial and legal record, help in clinical research,
support decision analysis
Guidelines for receiving verbal orders in an emergency Correct Answer-
record the orders in patients medical records, read back the order to
verify accuracy, date and not the time orders were issued in emergency,
record VO, the name of the physician or nurse practitioner followed by
nurses name and title, the registered professional nurse nurse must see
that the orders are transcribed according to procedure
Terminology used: Correct Answer-Medical terminology used to
facilitate communication, breakdown medical terminology into the three
parts prefix root suffix
Terminology Abbreviation notes Correct Answer-Keep to standard
abbreviation different areas or specialties vary, know approved
abbreviation for specific agency
Documentation Essentials Legal document: What you need: Correct
Answer-Black ink, contain facts and be accurate, legible, brief/concise,
,exact time (may be military time), logical by time and content,
Errors/Omissions, no blank spaces, signature
Good assessors are usuallly good charters why? Correct Answer-
Assessing from head to toe paining a good picture should chart what you
did and saw
Charting: Correct Answer-Takes time and practice, practice, proactive,
you will always be perfecting the skill
When to chart? Correct Answer-Admission, assuming care, transferring
a patient, discharging a patient
Types of entries: Correct Answer-Newly admitted patient, opening notes
for shift, interval notes(when something has changed), anything
abnormal, any change, test, lab, doctor visit, dietitian show orders
carried out, transfer discharge
Documentation essentials: Correct Answer-Patient teaching, entries
should be objective avoid good, bad, seems like, do symptom analysis
on complaints/pain, Entries must reflect patient needs if you find
something wrong you must chart what you did and how your patient
responded, dressing should not location attachments drainage not skin
condition if removed, tubes state type placement infusion site condition
drainage suction, Mar available for routine meds PRN are entered in
narrative notes with assessment intervention and response note meds not
given (when patient complains of pain state nurse notified ,
Psychosocial-LOC and safety, ADL-flow sheet/transfer needs, Jewelry-
, describe (gold-yellow) where sent and who recieved, spiritual care- not
expression of grief/anger symbols/rituals, sins of distress sources of
hope, safety:side rails ambulation call light restraints teaching about
safety incident form is fall, elderly:ADL mobility safety mental status
affective behavior
Methods of documentation: source oriented Correct Answer-Separate
division for each discipline, may be narrative
Methods of documentation problem oriented Correct Answer-data base,
problem list, plans, progress
Documentation formats-problem oriented: Correct Answer-SOAP:
subjective data, objective data, assessment, plan
APIE: assessment, problems, interventions, evaluations
Focus:Data, action, response
charting by exception
case management model
collaborative pathways
occurrence charting
computerized records
Documentation formats: Correct Answer-24 hour assessment -note
abnormal findings in narrative
kardex plan of care/needs list
Documentation is Correct Answer-The written or electronic legal record
of all pertinent interactions with the patient assessing diagnosing
planning implementing and evaluating
Characteristic of effective documentation Correct Answer-Consistent
with professional and agency standerds, complete , accurate, concise,
factual, organized and timely, legally prudent, confidential
What is confidential? Correct Answer-All information about patients
written on paper spoken aloud saved on commuter (Name, address,
phone, fax social security, reason the person is sick, assessments and
treatments patient receives, information about past health conditions)
A nurse who fails to log off a commuter after documenting patient care
has breached patient confidentiallity true or false Correct Answer-True
A patient has the right to obtain review and revise the patient
information in his or her health record True or false Correct Answer-
False
Records included: Correct Answer-client identification and demogrphic
data, informed consent for treatment and procedures, admission nursing
history, nursing diagnoses or problems, nursing or multidiscriplinary
care plan includes respiratory disease, records of nursing care treatment
and evaluation, medical history, medical diagnosis, therapy orders,
medical and health discipline progress notes, reports of physical
,examinations, reports of diagnostic studies, summary of operative
procedures, discharge plan and summary
Purpose of patient records Correct Answer-Communication with other
healthcare professionals, records of diagnostic and therapeutic orders,
care plannning, quality process and performance improvement, research,
decision analysis, education, credentialing regulation and legislation,
legal and historical documentation, reimbursement, facilitate patient
care, serve as a financial and legal record, help in clinical research,
support decision analysis
Guidelines for receiving verbal orders in an emergency Correct Answer-
record the orders in patients medical records, read back the order to
verify accuracy, date and not the time orders were issued in emergency,
record VO, the name of the physician or nurse practitioner followed by
nurses name and title, the registered professional nurse nurse must see
that the orders are transcribed according to procedure
Terminology used: Correct Answer-Medical terminology used to
facilitate communication, breakdown medical terminology into the three
parts prefix root suffix
Terminology Abbreviation notes Correct Answer-Keep to standard
abbreviation different areas or specialties vary, know approved
abbreviation for specific agency
Documentation Essentials Legal document: What you need: Correct
Answer-Black ink, contain facts and be accurate, legible, brief/concise,
,exact time (may be military time), logical by time and content,
Errors/Omissions, no blank spaces, signature
Good assessors are usuallly good charters why? Correct Answer-
Assessing from head to toe paining a good picture should chart what you
did and saw
Charting: Correct Answer-Takes time and practice, practice, proactive,
you will always be perfecting the skill
When to chart? Correct Answer-Admission, assuming care, transferring
a patient, discharging a patient
Types of entries: Correct Answer-Newly admitted patient, opening notes
for shift, interval notes(when something has changed), anything
abnormal, any change, test, lab, doctor visit, dietitian show orders
carried out, transfer discharge
Documentation essentials: Correct Answer-Patient teaching, entries
should be objective avoid good, bad, seems like, do symptom analysis
on complaints/pain, Entries must reflect patient needs if you find
something wrong you must chart what you did and how your patient
responded, dressing should not location attachments drainage not skin
condition if removed, tubes state type placement infusion site condition
drainage suction, Mar available for routine meds PRN are entered in
narrative notes with assessment intervention and response note meds not
given (when patient complains of pain state nurse notified ,
Psychosocial-LOC and safety, ADL-flow sheet/transfer needs, Jewelry-
, describe (gold-yellow) where sent and who recieved, spiritual care- not
expression of grief/anger symbols/rituals, sins of distress sources of
hope, safety:side rails ambulation call light restraints teaching about
safety incident form is fall, elderly:ADL mobility safety mental status
affective behavior
Methods of documentation: source oriented Correct Answer-Separate
division for each discipline, may be narrative
Methods of documentation problem oriented Correct Answer-data base,
problem list, plans, progress
Documentation formats-problem oriented: Correct Answer-SOAP:
subjective data, objective data, assessment, plan
APIE: assessment, problems, interventions, evaluations
Focus:Data, action, response
charting by exception
case management model
collaborative pathways
occurrence charting
computerized records
Documentation formats: Correct Answer-24 hour assessment -note
abnormal findings in narrative
kardex plan of care/needs list
