NURS 122 Lecture WEEK ONE UPDATED
ACTUAL Exam Questions and CORRECT
Answers
discussion - CORRECT ANSWER - an informal oral consideration of a subject by two or
more healthcare personnel to identify a problem or establish strategies
report - CORRECT ANSWER - oral, written, or computer-based communication intended
to convey information to others
The process of making an entry on a patient record is called - CORRECT ANSWER -
recording, charting, or documenting
clinical record - CORRECT ANSWER - a formal, legal document that provides evidence
of a patient's care
"The nurse has a duty to maintain confidentiality of all patient information" is said by who? -
CORRECT ANSWER - The American Nurses Association (ANA) Code of Ethics
PHI is the abbreviation for - CORRECT ANSWER - Protected Health Information
purposes of patient records include - CORRECT ANSWER - communication, planning
patient care, auditing health agencies, research, education, reimbursement, legal documentation,
healthcare analysis
the traditional patient record is called - CORRECT ANSWER - a source-oriented record
narrative charting consists of what? - CORRECT ANSWER - Written notes which include
routine care, normal findings, and patient problems
, examples of diagnostic reports are - CORRECT ANSWER - laboratory reports, x-ray
reports, CT scan reports
examples of consultation reports are - CORRECT ANSWER - physical therapy and
respiratory therapy
the abbreviation for POMR is - CORRECT ANSWER - problem-oriented medical record
what is a POMR? - CORRECT ANSWER - data is arranged according to the problems the
patient has rather than according to the source of the information
what are some advantages and disadvantages of a POMR? - CORRECT ANSWER -
advantages: they encourage collaboration, and that the problem list in the front of the chart alerts
caregivers to the patient's needs, making it easier to track the status of each problem
disadvantages: not all caregivers can use the charting format effectively, constant vigilance is
required to maintain an up-to-date problem list which can be inefficient
what is a database? - CORRECT ANSWER - all information known about the patient
SOAP is an acronym for - CORRECT ANSWER - subjective, objective, assessment, and
planning
subjective data - CORRECT ANSWER - what the person says about himself or herself
during history taking
objective data - CORRECT ANSWER - information that is seen, heard, felt, or smelled by
an observer; signs
assessment - CORRECT ANSWER - interpretation or conclusions drawn about the
subjective and objective data
ACTUAL Exam Questions and CORRECT
Answers
discussion - CORRECT ANSWER - an informal oral consideration of a subject by two or
more healthcare personnel to identify a problem or establish strategies
report - CORRECT ANSWER - oral, written, or computer-based communication intended
to convey information to others
The process of making an entry on a patient record is called - CORRECT ANSWER -
recording, charting, or documenting
clinical record - CORRECT ANSWER - a formal, legal document that provides evidence
of a patient's care
"The nurse has a duty to maintain confidentiality of all patient information" is said by who? -
CORRECT ANSWER - The American Nurses Association (ANA) Code of Ethics
PHI is the abbreviation for - CORRECT ANSWER - Protected Health Information
purposes of patient records include - CORRECT ANSWER - communication, planning
patient care, auditing health agencies, research, education, reimbursement, legal documentation,
healthcare analysis
the traditional patient record is called - CORRECT ANSWER - a source-oriented record
narrative charting consists of what? - CORRECT ANSWER - Written notes which include
routine care, normal findings, and patient problems
, examples of diagnostic reports are - CORRECT ANSWER - laboratory reports, x-ray
reports, CT scan reports
examples of consultation reports are - CORRECT ANSWER - physical therapy and
respiratory therapy
the abbreviation for POMR is - CORRECT ANSWER - problem-oriented medical record
what is a POMR? - CORRECT ANSWER - data is arranged according to the problems the
patient has rather than according to the source of the information
what are some advantages and disadvantages of a POMR? - CORRECT ANSWER -
advantages: they encourage collaboration, and that the problem list in the front of the chart alerts
caregivers to the patient's needs, making it easier to track the status of each problem
disadvantages: not all caregivers can use the charting format effectively, constant vigilance is
required to maintain an up-to-date problem list which can be inefficient
what is a database? - CORRECT ANSWER - all information known about the patient
SOAP is an acronym for - CORRECT ANSWER - subjective, objective, assessment, and
planning
subjective data - CORRECT ANSWER - what the person says about himself or herself
during history taking
objective data - CORRECT ANSWER - information that is seen, heard, felt, or smelled by
an observer; signs
assessment - CORRECT ANSWER - interpretation or conclusions drawn about the
subjective and objective data
