Nurs 3105 Exam 2 Questions With Complete Solutions
You speak with a doctor about your pt. When documenting your
encounter, what would you include?
-Time
-Date
-Who you spoke with
-What you said
-What they said
T/F Clients do not have the right to see their records.
FALSE
What are the methods of documentation?
-Narrative (story like format)
-Problem-oriented medical record/POMR (organized according
to to pt health care problems)
-SOAP, SOAPIE, PIE, DAR
What does SOAP stand for?
Subjective
Objective
Assessment
Plan
What is SOAP?
A way to organize info in progress note of nursing process
What are methods of reporting
,-Charting by exception (CBE)
-Case management plan
-Critical pathways
What does Charting by exception (CBE) focus on?
-Documenting deviations
-Abnormal
What does case management plan and critical pathways
incorporate?
Multidisciplinary approach to care, identifies pt problem, key
interventions, and expected outcomes w/in a time frame.
What is the admission nursing history form?
Guides nurse through complete assessment to identify relevant
nursing diagnoses or problems
What do flow sheets and graphic records do?
Help team members quickly see pt trends over time and decrease
time spent on writing narrative notes
What are examples of flow sheets and graphic records?
-Vital signs
-Lab Reports
What are standardized care plans or clinical care guidelines
(CPGs)?
Preprinted, established guidelines used to care for pts who have
similar health problems
What are incident or occurrence reports?
,Objective account of what happened, what you observed and
any follow-up action taken, including notification of the pt's
health care provider in medical records.
Why do we use incident or occurrence reports?
Used to document any event that is not consistent with routine
operation of a health care unit or routine care of a pt
What would be included in discharge instructions?
-Step-by-step instructions on how to perform procedures
-Review signs and symptoms of complications
-Instruction in potential food interactions or modified diet
-Names and numbers of resources
-Time of discharge
-Mode of transportation
-Who accompanied pt
Who completes discharge?
RN
What three terms best describe informatics as it applies to
nursing?
-Data
-Information
-Knowledge
( examples are: EKG, digital thermometer, BP machines, Pulse
Ox, and other monitors.)
What is Technology Informatics Guiding Education Reform
(TIGER)
, Focused on better preparing clinical workforce to use
technology and informatics to improve delivery of pt care
What did TIGER transform into?
Healthcare Information and Management System Society (HI
What are advantages with nursing informatics?
-Pt Safety
-Gain better access of info and resources
-Reduced errors
-Decreased hospital costs
-In compliance with TJB
-Track Records
What are the two types of wounds?
-Open
-Closed
What is an example of an open wound?
Lacerations, Incisions, punctures, abrasions
What is an example of a closed wounds?
ecchymosis and hematomas
What are the functions of the skin?
-Protection
-Regulation of body temp
-psychosocial
-Sensation
-Synthesize vitamin D
You speak with a doctor about your pt. When documenting your
encounter, what would you include?
-Time
-Date
-Who you spoke with
-What you said
-What they said
T/F Clients do not have the right to see their records.
FALSE
What are the methods of documentation?
-Narrative (story like format)
-Problem-oriented medical record/POMR (organized according
to to pt health care problems)
-SOAP, SOAPIE, PIE, DAR
What does SOAP stand for?
Subjective
Objective
Assessment
Plan
What is SOAP?
A way to organize info in progress note of nursing process
What are methods of reporting
,-Charting by exception (CBE)
-Case management plan
-Critical pathways
What does Charting by exception (CBE) focus on?
-Documenting deviations
-Abnormal
What does case management plan and critical pathways
incorporate?
Multidisciplinary approach to care, identifies pt problem, key
interventions, and expected outcomes w/in a time frame.
What is the admission nursing history form?
Guides nurse through complete assessment to identify relevant
nursing diagnoses or problems
What do flow sheets and graphic records do?
Help team members quickly see pt trends over time and decrease
time spent on writing narrative notes
What are examples of flow sheets and graphic records?
-Vital signs
-Lab Reports
What are standardized care plans or clinical care guidelines
(CPGs)?
Preprinted, established guidelines used to care for pts who have
similar health problems
What are incident or occurrence reports?
,Objective account of what happened, what you observed and
any follow-up action taken, including notification of the pt's
health care provider in medical records.
Why do we use incident or occurrence reports?
Used to document any event that is not consistent with routine
operation of a health care unit or routine care of a pt
What would be included in discharge instructions?
-Step-by-step instructions on how to perform procedures
-Review signs and symptoms of complications
-Instruction in potential food interactions or modified diet
-Names and numbers of resources
-Time of discharge
-Mode of transportation
-Who accompanied pt
Who completes discharge?
RN
What three terms best describe informatics as it applies to
nursing?
-Data
-Information
-Knowledge
( examples are: EKG, digital thermometer, BP machines, Pulse
Ox, and other monitors.)
What is Technology Informatics Guiding Education Reform
(TIGER)
, Focused on better preparing clinical workforce to use
technology and informatics to improve delivery of pt care
What did TIGER transform into?
Healthcare Information and Management System Society (HI
What are advantages with nursing informatics?
-Pt Safety
-Gain better access of info and resources
-Reduced errors
-Decreased hospital costs
-In compliance with TJB
-Track Records
What are the two types of wounds?
-Open
-Closed
What is an example of an open wound?
Lacerations, Incisions, punctures, abrasions
What is an example of a closed wounds?
ecchymosis and hematomas
What are the functions of the skin?
-Protection
-Regulation of body temp
-psychosocial
-Sensation
-Synthesize vitamin D
