NUR 109 Nursing Documentation (Exam 1)
Questions With Correct Answers
Define: Documentation - CORRECT ANSWER✔✔-Documentation is the act of
| | | | | | | | |
recording patient status and care. Key Point: Documentation can be in written or
| | | | | | | | | | | | |
electronic form or in a combination of the two forms.
| | | | | | | | |
Documentation - CORRECT ANSWER✔✔-•Book Definition: | | | |
•The act of making a written/electronic record
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•Documenting = Recording = Charting | | | |
•Reporting = oral transmission of information
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•Painting a Picture of Client Care
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•Includes client responses to interventions/treatments
| | | |
•Chronological Timeline |
•Record of important facts
| | |
Purposes of Documentation - CORRECT ANSWER✔✔-Identify actual and potential
| | | | | | | |
health problems
| |
Make nursing diagnoses
| |
Plan appropriate care
| |
Evaluate patient's responses to treatment
| | | |
-Documentation can be your Ally: | | | |
, -Aids in identifying problem areas, planning, and evaluating care
| | | | | | | |
- Documents/Provides opportunity to take credit for what was observed about
| | | | | | | | | | |
and done for client
| | |
-Communication with other health care providers | | | | |
- Demonstrates compliance with standards of care
| | | | | |
- Ensures reimbursement by complying with third party payer standards
| | | | | | | | |
- Provides legal protection to nurse and employer
| | | | | | |
-Used in research, to support decisions base on analysis of records, and in quality
| | | | | | | | | | | | | |
improvement
Sources of Documentation Standards - CORRECT ANSWER✔✔--ANA
| | | | | |
-Centers for Medicare and Medicaid
| | | |
-State Nurse Practice Acts
| | |
-Joint Commission
|
What do these organizations emphasize for documentation? - CORRECT
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ANSWER✔✔--All emphasize: |
-Ongoing assessment |
-Client teaching and response to teaching/evidence of learning/need for further
| | | | | | | | | |
teaching
-Client response to all medications, treatments, and interventions
| | | | | | |
-Relevant statements made by client in quotation marks
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-Demonstration of use of nursing process | | | | |
Questions With Correct Answers
Define: Documentation - CORRECT ANSWER✔✔-Documentation is the act of
| | | | | | | | |
recording patient status and care. Key Point: Documentation can be in written or
| | | | | | | | | | | | |
electronic form or in a combination of the two forms.
| | | | | | | | |
Documentation - CORRECT ANSWER✔✔-•Book Definition: | | | |
•The act of making a written/electronic record
| | | | | |
•Documenting = Recording = Charting | | | |
•Reporting = oral transmission of information
| | | | |
•Painting a Picture of Client Care
| | | | |
•Includes client responses to interventions/treatments
| | | |
•Chronological Timeline |
•Record of important facts
| | |
Purposes of Documentation - CORRECT ANSWER✔✔-Identify actual and potential
| | | | | | | |
health problems
| |
Make nursing diagnoses
| |
Plan appropriate care
| |
Evaluate patient's responses to treatment
| | | |
-Documentation can be your Ally: | | | |
, -Aids in identifying problem areas, planning, and evaluating care
| | | | | | | |
- Documents/Provides opportunity to take credit for what was observed about
| | | | | | | | | | |
and done for client
| | |
-Communication with other health care providers | | | | |
- Demonstrates compliance with standards of care
| | | | | |
- Ensures reimbursement by complying with third party payer standards
| | | | | | | | |
- Provides legal protection to nurse and employer
| | | | | | |
-Used in research, to support decisions base on analysis of records, and in quality
| | | | | | | | | | | | | |
improvement
Sources of Documentation Standards - CORRECT ANSWER✔✔--ANA
| | | | | |
-Centers for Medicare and Medicaid
| | | |
-State Nurse Practice Acts
| | |
-Joint Commission
|
What do these organizations emphasize for documentation? - CORRECT
| | | | | | | | |
ANSWER✔✔--All emphasize: |
-Ongoing assessment |
-Client teaching and response to teaching/evidence of learning/need for further
| | | | | | | | | |
teaching
-Client response to all medications, treatments, and interventions
| | | | | | |
-Relevant statements made by client in quotation marks
| | | | | | |
-Demonstration of use of nursing process | | | | |
