Foundations Of Nursing 9th Edition Cooper - Ch 3: Documentation Test Bank Actual Exam and Correct Answers Update.

Auditors - Answer People appointed to examine patient charts and health records to assess quality of care Chart (Health Care Record) - Answer Legal record that is used to meet many demands of the health accreditation, medical insurance, and legal systems. Charting - Answer Process of recording information on a patient's chart Charting By Exception - Answer Recording only new data or changes in patient status or care; charting the exceptions to the previously recorded data. Computers On Wheels - Answer Point-Of-Care systems housed on wheeled carts Database - Answer Large store or bank of information, as in forming the patient's nursing diagnosis Diagnosis Related Groups - Answer a system that classifies patients by age, diagnosis, and surgical categories; used to predict the use of hospital resources including length of stay Documenting - Answer Process of adding information to the chart, usually at prescribed intervals Electronic Health Record - Answer An electronic patient record designed for health information exchange between facilities Electronic Medical Record - Answer An electronic patient record designed for health information exchange only within a facility Informatics - Answer The process of retrieving, storing, and transmitting data. ISBAR - Answer Identification