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Exam (elaborations)
NUR 1020C Exam 2 study guide (term 1) Questions and Answers.
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When documenting what is needed? - Always in Black ink and include: date, time, Signature, and credentials. Need to accessible, accurate, timely, and nursing documentation is clear, concise, complete, and objective. SOAP - Subjective, objective, Assessment, Plan PIE - Problem, intervention, evaluation SBAR (communication) - Situation, Background, Assessment, Recommendation Health Informatics - A discipline in which health data are stored, analyzed and disseminated
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