Chapter 7 deWit's Fundamental Concepts and Skills for Nursing (Practice questions with error-free answers)

case management charting correct answers Documentation that tracks variances from the clinical pathway Charting correct answers Documentation of the nursing process, treatment, and associated care. Charting by Exception correct answers Documentation that focuses on deviations from predefined norms, using preset protocols and standards of care. Computer-assisted charting correct answers Documentation in which data are input via the computer. computerized provider order entry (CPOE) correct answers The entering of provider orders into the medical record via computer. electronic health record (EHR) correct answers Health record entered into a computer's software program that is updated via the computer. focus charting correct answers Documentation that centers on the patient from a positive perspective; this form of documentation has three components: data, action, and response. medical record correct answers Paper or electronic record that contains all orders, test, treatments, and care that occurred during the time a person was under the care of a health care provider. PIE charting correct answers Method of documentation in which "P" means problem identification, "I" means interventions, and "E" means evaluation. problem-oriented medical record (POMR) charting correct answers Documentation that focuses on patient status, emphasizes the problem-solving approach to patient care, and provides a