NR 501 WEEK 8 NURSING THEORY QUIZ
(SOLUTIONS).
documenting in nursing is defined as - CORRECT_ANSWER_the process of
documenting nursing information about nursing care in the health records
methods of documentation (2) - CORRECT_ANSWER_narrative and problem-
orientated medical record
what is narrative documentation ? - CORRECT_ANSWER_The traditional method
(story-like format)
what percentage of nursing practice time does documentation take up ? -
CORRECT_ANSWER_around 25%
,documentation must be ... - CORRECT_ANSWER_accurate, comprehensive and
reflect standards of nursing practice
what are common record keeping forms - CORRECT_ANSWER_- Admission nursing
history form
- Flow sheets and graphic records
- Patient summary or Kardex
- Standardized care plans
- Discharge summary forms
acuity rating systems - CORRECT_ANSWER_Determine the hours of care and
number of staff required for a given group of patient every shift or every 24 hours
does an acuity rating help justify the number and qualification of staff needed to
safely care for patients? - CORRECT_ANSWER_yes
Documentation in HOME health care - CORRECT_ANSWER_-Patient and family
often guardians of information if a hard copy of the health care record is kept in
patients home
- communication is critical
, Documentation in the LONG-TERM health care setting - CORRECT_ANSWER_-
Documentation is used to review levels of care given to and needed by the
residents in long term care facilities
-different agencies will have different standards and policies for documentation
Documenting communication with providers - CORRECT_ANSWER_- Telephone
calls made to health care provider
- Telephone orders
-Verbal orders
- Change of shift reports
-transfer reports
-SBAR
-I-SBAR-R
-incident/occurrence report
what do change in shift reports need - CORRECT_ANSWER_- Transfer of
accountability practice guidelines
- Background information
- Assessment