LVN EXAM 3; CHAPTER 7-10
questions n answers
PURPOSE OF DOCUMENTATION - correct answer ✔✔ -WRITTEN RECORD OF THE HISTORY,
TREATMENT CARE, AND RESPONSE OF CARE OF THE PT
-GUIDE FOR REIMBRUSHMENT
-EVIDENCE UNDER THE COURT OF LAW
-SHOWS USE OF NURSING PROGRESS
FACE SHEET - correct answer ✔✔ PATIENT DATA
PROVIDER ORDER - correct answer ✔✔ DIRECTIVES ORDER FROM THE PROVIDER
NURSING CARE - correct answer ✔✔ PLAN OF CARE FOR PATIENT INCLUDES GOALS AND
OUTCOME
NURSING NOTES - correct answer ✔✔ DOCUMENTATION OF THE NURSING PROCESS (ANPIE)
MAR - correct answer ✔✔ MEDICATION OF RECORD
LAB/RADIOOLOGY REPORTS - correct answer ✔✔ RESULTS OF LAB AND RADIOLOGY
CARE FLOW SHEET - correct answer ✔✔ FORM THAT MARKS ALL PATIENTS CARE BY CHECKIBNG
BOXES AND MAKING SHORT ENTRIE
,INTAKE AND OUTPUT RECORD - correct answer ✔✔ FORM THAT RECORDS ALL INTAKE AND
OUTTAKE FOR 24 HR PERIOD AND PROVIDES FLUID BALANCE FOR THE PATIENT
CONSENT FORMS - correct answer ✔✔ ADDED TO RECORD AS NEEDED TO PROVIDED CONSENT
FOR SPECIFIC PROCEDURES
( SURGERY, BLOOD TRANSFUSION, SEDATION)
METHODS OF CHARTING: SOURCE-ORIENTATED - correct answer ✔✔ ORGANIZED ACCORDING
TO SOURCE OF INFORMATION
-SEPARATE FORMS FOR NURSES, DRS, DIETITIANS AND OTHER HEALTH CARE PROFESSIONALS TO
DOC. ASSESSMENT FINDINGS AND PLAN THE PATIENTS CARE
-REQUIRES INFORMATION OF PATIENT CARE IN CHRONOLOGICAL ORDER
ADVANTAGES:
1. INFO IN CHRONOLOGICAL ORDER
2. DOCUMENTS PATIENTS BASELINE CONDITION FOR EACH SHIFT
3. INDICATES ASPECTS OF ALL STEPS IN NURSING PROCESS
DISADVANTAGES:
1. MAKES IT DIFFICULT TO SEPARATE PERTINENT FROM IRRELEVANT
2. REQUIRES EXTENSIVE CHARTING BY STAFFF
3. DISCOURAGES DR AND HEALTH CARE STAFF FROM READING ALL PARTS OF THE CHART
METHODS OF CHARTING: PROBLEM-ORIENTATED MEDICAL RECORD (POMR) - correct answer
✔✔ FOCUSES ON PATIENT STATUS RATHER THAN ON MEDICAL AND NURSING CARE
, -FIVE BASIC PARTS : PROBLEM LIST, PLAN, PROGRESS NOTES, AND DISCHARGE SUMMARY
PROGRESS NOTE FORMAT:
SOAP NOTE- SUBJECTIVE DATE, OBJECTIVE DATE, ASSESSMENT DATA, PLAN
ADVANTAGES:
1. DOCS. CARE BY FOCUSING ON PATIENTS PROBLEM
2. PROMOTES POMR TO CARE
3. IMPROVES CARE AND COMMUNICATION
4. ALLOWS EASY ASSESS TO MR IN EVALUATING STAFF PERFORMANCE OR QUALITY OF PATIENT
CARE
5. REQUIRES CONTINUAL EVAULATION AND REVISION OF THE CARE PLAN
6. REINFORCES APPLICATION OF THE NURSING PROCESS
DISADVANTAGES:
1. RESULTS IN LOSS OF CHRONOLOGICAL CHARTING
2. MORE DIFFCULT TO TRACK TRENDS IN PATIENTS STATUS
3. FRAGMENTS DATE B/C MORE FLOWSHEETS ARE REQUIRED
PIE CHARTING - correct answer ✔✔ P-PROBLEM IDENTIFCATION
I- DENFICATION
E-VALUTION
ADVANTAGES: FOLLOWS THE NURSING PROCESS AND USES NURSING TO DIAGNOSES WHILE
PLACING THE PLAN WITHIN THE NURSES PROGRESS NOTES
questions n answers
PURPOSE OF DOCUMENTATION - correct answer ✔✔ -WRITTEN RECORD OF THE HISTORY,
TREATMENT CARE, AND RESPONSE OF CARE OF THE PT
-GUIDE FOR REIMBRUSHMENT
-EVIDENCE UNDER THE COURT OF LAW
-SHOWS USE OF NURSING PROGRESS
FACE SHEET - correct answer ✔✔ PATIENT DATA
PROVIDER ORDER - correct answer ✔✔ DIRECTIVES ORDER FROM THE PROVIDER
NURSING CARE - correct answer ✔✔ PLAN OF CARE FOR PATIENT INCLUDES GOALS AND
OUTCOME
NURSING NOTES - correct answer ✔✔ DOCUMENTATION OF THE NURSING PROCESS (ANPIE)
MAR - correct answer ✔✔ MEDICATION OF RECORD
LAB/RADIOOLOGY REPORTS - correct answer ✔✔ RESULTS OF LAB AND RADIOLOGY
CARE FLOW SHEET - correct answer ✔✔ FORM THAT MARKS ALL PATIENTS CARE BY CHECKIBNG
BOXES AND MAKING SHORT ENTRIE
,INTAKE AND OUTPUT RECORD - correct answer ✔✔ FORM THAT RECORDS ALL INTAKE AND
OUTTAKE FOR 24 HR PERIOD AND PROVIDES FLUID BALANCE FOR THE PATIENT
CONSENT FORMS - correct answer ✔✔ ADDED TO RECORD AS NEEDED TO PROVIDED CONSENT
FOR SPECIFIC PROCEDURES
( SURGERY, BLOOD TRANSFUSION, SEDATION)
METHODS OF CHARTING: SOURCE-ORIENTATED - correct answer ✔✔ ORGANIZED ACCORDING
TO SOURCE OF INFORMATION
-SEPARATE FORMS FOR NURSES, DRS, DIETITIANS AND OTHER HEALTH CARE PROFESSIONALS TO
DOC. ASSESSMENT FINDINGS AND PLAN THE PATIENTS CARE
-REQUIRES INFORMATION OF PATIENT CARE IN CHRONOLOGICAL ORDER
ADVANTAGES:
1. INFO IN CHRONOLOGICAL ORDER
2. DOCUMENTS PATIENTS BASELINE CONDITION FOR EACH SHIFT
3. INDICATES ASPECTS OF ALL STEPS IN NURSING PROCESS
DISADVANTAGES:
1. MAKES IT DIFFICULT TO SEPARATE PERTINENT FROM IRRELEVANT
2. REQUIRES EXTENSIVE CHARTING BY STAFFF
3. DISCOURAGES DR AND HEALTH CARE STAFF FROM READING ALL PARTS OF THE CHART
METHODS OF CHARTING: PROBLEM-ORIENTATED MEDICAL RECORD (POMR) - correct answer
✔✔ FOCUSES ON PATIENT STATUS RATHER THAN ON MEDICAL AND NURSING CARE
, -FIVE BASIC PARTS : PROBLEM LIST, PLAN, PROGRESS NOTES, AND DISCHARGE SUMMARY
PROGRESS NOTE FORMAT:
SOAP NOTE- SUBJECTIVE DATE, OBJECTIVE DATE, ASSESSMENT DATA, PLAN
ADVANTAGES:
1. DOCS. CARE BY FOCUSING ON PATIENTS PROBLEM
2. PROMOTES POMR TO CARE
3. IMPROVES CARE AND COMMUNICATION
4. ALLOWS EASY ASSESS TO MR IN EVALUATING STAFF PERFORMANCE OR QUALITY OF PATIENT
CARE
5. REQUIRES CONTINUAL EVAULATION AND REVISION OF THE CARE PLAN
6. REINFORCES APPLICATION OF THE NURSING PROCESS
DISADVANTAGES:
1. RESULTS IN LOSS OF CHRONOLOGICAL CHARTING
2. MORE DIFFCULT TO TRACK TRENDS IN PATIENTS STATUS
3. FRAGMENTS DATE B/C MORE FLOWSHEETS ARE REQUIRED
PIE CHARTING - correct answer ✔✔ P-PROBLEM IDENTIFCATION
I- DENFICATION
E-VALUTION
ADVANTAGES: FOLLOWS THE NURSING PROCESS AND USES NURSING TO DIAGNOSES WHILE
PLACING THE PLAN WITHIN THE NURSES PROGRESS NOTES
