ANASWERS!!
What are the purposes of patient charts? - ANSWER1. documented communication
2.permanent record for accountability
3. legal record of care
4. teaching
5. research and data collection
What do patient charts provide? - ANSWERConcise, accurate, and permanent
record of past and current medical and nursing problems, plans for care, care given,
and the patient's responses to various treatments of care
What is focus charting? - ANSWERmodified list of patient problem statements that
are used as an index for nursing documentation.
uses the nursing process and the more positive concept of the patients needs rather
than medical diagnoses and problems
POMR - ANSWERProblem Oriented Medical Record
What is POMR charting? - ANSWERorganized according to scientific problem
solving system or method.
The principal sections are database, problem list, care plan, and progress notes
What is DARE used for? - ANSWERfocus charting (Data, Action, Response,
Education)
Why are outside agencies in Long Term healthcare documentation important? -
ANSWERplay an instrumental role in determining standards and policies for
documentation
What is OBRA? - ANSWEROmnibus Budget Reconciliation Act of 1987 instituted
significant Medicare and Medicaid requirements for long-term care provision and
documentation.
Are minimum data sets and regulated standards for resident assessments,
individualized care plans, and qualifications for health care providers
drainage - ANSWERflow of fluids from a wound or cavity
Exudate - ANSWERfluid, such as pus, that leaks out of an infected wound
Pruitis - ANSWERitching
neoplastic - ANSWERabnormal growth of tissues
what do signs accompany? - ANSWERsymptoms