NUR 112 Exam 1 Questions with Verified
Correct Answers
Elements of Documentation (Guidelines)
- accessible
- accurate
- relevant
- consistent
- auditable
- clear
- concise/ complete
- legible/readable
-thoughtful
- timely
- sequential
- reflective of the nursing process
- retrievable on a permanent basis in a nursing- specific manner.
Who should document?
Whoever is responsible for the nurses care should chart but others can chart in as well.
Everyone should document!!!
Why should you document without error?
Poor documentation can be presumed as medical negligence. "CYA".
Make sure you're documenting without error/ i.e. Don't document the wrong BP. Can
possibly affect medication dosage.
Errors make nurses look less credible. Which can affect credibility.
,What is informatics?
computer and software systems (may include pager system any type of tech)
Should you skip lines if you're charting?
No!
Approved abreviations
A.C.- Before meals
b.i.d.- twice a day
c - with
D/C- discontinue or discharge
gtt, GTT- drops
IVPB- intravenous piggyback
mg-milligram
mcg- microgram
O.D.- right eye
O.S.- left eye
O.U.- both eyes
P- after
p.c.- after meals
PRN, p.r.n.- as needed
P.O., p.o.- by mouth
p.r., R- rectally
q.h.- every hour
q.i.d.- four times a day
QS- quantity sufficient
,s- without
ss- one-half
t.i.d.- three times a day
What is HIPAA
Health Insurance Portability and Accountability Act
Potential Breaches in Patient Confidentiality
Displaying information on a public screen
-Sending confidential e-mail messages via public networks
-Sharing printers among units with differing functions
-Discarding copies of patient information in trash cans
-Holding conversations that can be overheard
-Faxing confidential information to unauthorized persons
-Sending confidential messages overheard on pagers
Hypothetically, if a patient had yellow skin, was not wearing pants, was smiling, and its
stomach is sticking out, and the patient also states, "I'm rumbly in my tummly." How
would you chart this?
Patient has generalized jaundice. Ambulating in room. Patient is not wearing pants.
Protruding abdomen. The patient is smiling. No signs of distress. Patient states I'm rumbly in
my tummy. Patient "I'm hungry".
Patient's have the right to:
-See and copy their health record
-Update their health record
-Get a list of disclosures
, -Request a restriction on certain uses or disclosures
-Choose how to receive health information
what can patient's NOT do to their paperwork?
patient's cannot revise info
Documentation
written or electronic legal record kept by nurses for assessing and planning
What is the nursing process?
Assessment
Diagnosis
Planning
Implementation
Evaluation
content must be factual - meaning what can you see?
examples: Shortness of breath, cardiac arrest, patient is in use of oxygen with 2 Liters, etc.
Factual charting example vs. not
Factual: patient is lying in bed at 15 degrees with eyes closed
not: patient is sleeping
factual: BP is 130/70 taken at 1430not: patient BP is within normal limits (Always use
numbers if available)
Who is responsible for their chart?
The person who completed the surgical procedure (the process of removing or handling
sterile materials)
Correct Answers
Elements of Documentation (Guidelines)
- accessible
- accurate
- relevant
- consistent
- auditable
- clear
- concise/ complete
- legible/readable
-thoughtful
- timely
- sequential
- reflective of the nursing process
- retrievable on a permanent basis in a nursing- specific manner.
Who should document?
Whoever is responsible for the nurses care should chart but others can chart in as well.
Everyone should document!!!
Why should you document without error?
Poor documentation can be presumed as medical negligence. "CYA".
Make sure you're documenting without error/ i.e. Don't document the wrong BP. Can
possibly affect medication dosage.
Errors make nurses look less credible. Which can affect credibility.
,What is informatics?
computer and software systems (may include pager system any type of tech)
Should you skip lines if you're charting?
No!
Approved abreviations
A.C.- Before meals
b.i.d.- twice a day
c - with
D/C- discontinue or discharge
gtt, GTT- drops
IVPB- intravenous piggyback
mg-milligram
mcg- microgram
O.D.- right eye
O.S.- left eye
O.U.- both eyes
P- after
p.c.- after meals
PRN, p.r.n.- as needed
P.O., p.o.- by mouth
p.r., R- rectally
q.h.- every hour
q.i.d.- four times a day
QS- quantity sufficient
,s- without
ss- one-half
t.i.d.- three times a day
What is HIPAA
Health Insurance Portability and Accountability Act
Potential Breaches in Patient Confidentiality
Displaying information on a public screen
-Sending confidential e-mail messages via public networks
-Sharing printers among units with differing functions
-Discarding copies of patient information in trash cans
-Holding conversations that can be overheard
-Faxing confidential information to unauthorized persons
-Sending confidential messages overheard on pagers
Hypothetically, if a patient had yellow skin, was not wearing pants, was smiling, and its
stomach is sticking out, and the patient also states, "I'm rumbly in my tummly." How
would you chart this?
Patient has generalized jaundice. Ambulating in room. Patient is not wearing pants.
Protruding abdomen. The patient is smiling. No signs of distress. Patient states I'm rumbly in
my tummy. Patient "I'm hungry".
Patient's have the right to:
-See and copy their health record
-Update their health record
-Get a list of disclosures
, -Request a restriction on certain uses or disclosures
-Choose how to receive health information
what can patient's NOT do to their paperwork?
patient's cannot revise info
Documentation
written or electronic legal record kept by nurses for assessing and planning
What is the nursing process?
Assessment
Diagnosis
Planning
Implementation
Evaluation
content must be factual - meaning what can you see?
examples: Shortness of breath, cardiac arrest, patient is in use of oxygen with 2 Liters, etc.
Factual charting example vs. not
Factual: patient is lying in bed at 15 degrees with eyes closed
not: patient is sleeping
factual: BP is 130/70 taken at 1430not: patient BP is within normal limits (Always use
numbers if available)
Who is responsible for their chart?
The person who completed the surgical procedure (the process of removing or handling
sterile materials)
