NUR2010 Chapter 26 -
Documentation Test Latest
Update
interprofessional communication - Answer Means by which patient needs and progress,
individual therapies, patient education, and discharge planning are conveyed to others
in the health care team.
legal documentation - Answer Describes exactly what happens to the patient and must
follow agency standards
diagnostic-related groups - Answer Classification system based on patient's medical
diagnoses that supports reimbursement.
education - Answer Learning the nature of an illness and the individual patient's
responses
research - Answer gathering of statistical data of clinical disorders, complications,
therapies, recovery, and death
auditing - Answer Objective, ongoing reviews to determine the degree to which quality
improvement standards are met.
narrative - Answer storylike format
focus charting - Answer uses data, action, and response (DAR)
PIE notes - Answer problem, intervention, evaluation
charting by exception - Answer Focuses on deviations from the established norm or
abnormal findings; highlights trends and changes
admission nursing history forms - Answer Provides baseline data to compare with
changes in the patient's condition.
flow sheets - Answer Provides current information that is accessible to all members of
the health care team
pt care summary - Answer provides the most current information that has been entered
into the EHR
acuity records - Answer Level is based on the type and number of nursing interventions
required over a 24-hour period.
Documentation Test Latest
Update
interprofessional communication - Answer Means by which patient needs and progress,
individual therapies, patient education, and discharge planning are conveyed to others
in the health care team.
legal documentation - Answer Describes exactly what happens to the patient and must
follow agency standards
diagnostic-related groups - Answer Classification system based on patient's medical
diagnoses that supports reimbursement.
education - Answer Learning the nature of an illness and the individual patient's
responses
research - Answer gathering of statistical data of clinical disorders, complications,
therapies, recovery, and death
auditing - Answer Objective, ongoing reviews to determine the degree to which quality
improvement standards are met.
narrative - Answer storylike format
focus charting - Answer uses data, action, and response (DAR)
PIE notes - Answer problem, intervention, evaluation
charting by exception - Answer Focuses on deviations from the established norm or
abnormal findings; highlights trends and changes
admission nursing history forms - Answer Provides baseline data to compare with
changes in the patient's condition.
flow sheets - Answer Provides current information that is accessible to all members of
the health care team
pt care summary - Answer provides the most current information that has been entered
into the EHR
acuity records - Answer Level is based on the type and number of nursing interventions
required over a 24-hour period.
