Review Questions Potter Perry Chapter
26 - Documentation and Informatics
Questions and Correct Answers the
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Documentation
✓ anything written or printed that you rely on as record or proof
Accreditation
✓ Joint Commission specifies guidelines for documentation
Define Diagnosis-realted group (DRG)
✓ series of decision trees designed to cluster groups of clients together by diagnosis,surgical
procedures, complications, co-morbidities, and age
Explain the new rights for clients related to HIPPA
✓ client education on privacy protections
✓ ensuring client's access to his or her medical records
✓ receiving client consent before information is released
✓ providing recourse if privacy protections are violated
The standards of documentation by the Joint Commission require
✓ requires documentation within the context of the nursing process, as well as evidenceof
client and family teaching and discharge planning
Client record
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✓ is a confidential, permanent legal documentation of information relevant to a
client'shealth care
Reports
✓ oral, written, or audiotaped exchanges between caregivers
Consultations
✓ form of discussion whereby one professional caregiver gives formal advice about the
level of care of a client to another caregiver
Referrals
✓ an arrangement for services by another care provider
Communication
✓ means by which client needs and progress, individual therapies, client education, and
discharge planning are conveyed to others in the health care team
Legal Documentation
✓ Once of the best defenses for legal claims
Financial Billing
✓ To determine the accurate and timely reimbursement
Education
✓ Learning the nature of an illness and the individual client's responses
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