NURS 371 SELU Gibbs Exam 1.docx

NURS 371 SELU Gibbs Exam 1
b b b b b




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b b b




1. documentationrecord of pt status and care. b b b b b b




can be written, electronic, or a combo
b b b b b b




2. reporting oral communication to maintain continuity of care,
b b b b b b b




build team relationships, and collaborate to
b b b b b b




improve patient care b b




3. - communicationuses
documentation
- continuity of care
b




b b




- quality improvement b




- legal record b




- planning/evaluating client outcomes b b




Clear5 C's of documentation
4. b b b




Complete
Concise
Comprehensive Correct b




5. documenting, recording, b b
interchangeable
and charting are
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each discipline recordsrecord
6. source-oriented
b their findings in separate sections of health record
b




b
b b




b
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system

7. advantages to source- everything is nice, neat in its separate section b b
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oriented record systems b b




info is fragmented
8. disadvantages to source-
b b




b b




oriented record systems b b




9. problem-oriented
organized record
around the patient's
b problems. 4 parts: database, problem list, plan of care,
b b
b
b
b
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systems progress notes b




10. advantages to problem-ori- makes monitoring progress easier ented
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record systems b





b b

, NURS 371 SELU Gibbs Exam 1
b b b b b




Study online at https://quizlet.com/_dom3jy
b b b




11.
disadvantages to prob- requires cooperative spirit among healthcare lem- b b b b b b b




oriented record sys- personnel tems
b b b




12. charting by exception b b b only significant findings are documented. as-
b b b b b




(CBE) sumes all standards have been met and pt b b b b b b b b




responded normally unless a separate entry has b b b b b b b




been made b




13. advantages of charting by reduces time spent on charting and increasesb b b b b b b b b b b




exception time caring for pt b b b




14. disadvantages of charting information is omitted which leads to med/pt by b b b b b b b b b b b




exception errors b




15. confidentiality breaches leaving info in public. discussing pt in public. staying
b b b b b b b b b b




logged in to computer. sharing passwords. improperly accessing info not r/t your
b b b b b b b b b b b b




assignment

16. advantages of EHR enhances communication, improves data ac- b b b b b b




cess, saves time, improves quality, safe b b b b b




17. disadvantages of EHR b b expensive, downtime, change is difficult b b b b




18. Nursing Process ADPIE: assessment, diagnosis, planning,
b b b b b




implementation, evaluation b




19. Clinical Judgement Model RAPGTE: recognize cues, analyze cues, prioritize
b b b b b b b b b




hypothesis, generate solutions, take action, evaluate outcomesb b b b b b




20. PIE charting
b problem, intervention, evaluation b b




b b