NUR 170 Final Exam Review
Expressed Consent Example: "Okay, we are taking your blood." PT gives arm
Implied Consent PT is not breathing, but no DNR
System within the hospital - login access only; permission required. (note th
Intranet
different than internet)
EHR Electronic Health Record
On call Dr. can skype or even treat. At times PT can call and speak to an RN
Telehealth
the phone
EMR Electronic Medical Record
Diagnosis Related Group: basis for establishing reimbursement for client ca
DRG (Medicare). Main problem with DRG's is when the PT care falls off the "expe
path of care"
, NUR 170 Final Exam Review
type of progress note
S - subjective
O - objective
SOAPIER A - assessment
P - plan
I - intervention
E - evaluation
R - revisions
type of progress note
PAO P - problem
A - action
O - outcome
type of progress note
PIE P - problem
I - intervention
E - evaluation
, NUR 170 Final Exam Review
type of progress note
DAR D - data
A - action
R - response
Focuses on documenting deviations from established norm or abnormal fin
(each facility has their own defined normal limits)
Charting by Exception (CBE)
Reduces documentation times and highlights trends and PT's condition
Can pose legal risks if RNs are not disciplined
OBRA Omnibus Budget Reconciliation Act of 1987
Terms NOT to use while documenting Passive words/phrases; example: appears, seems, apparently
BAD example: client seems anxious
GOOD example: client has increased pulse, increased RR, and increased
Examples of factual documentation
restlessness.
Client states "I feel anxious"
, NUR 170 Final Exam Review
P - patient population of interest
I - intervention of interest
PICOT C - comparison of interest
O - outcome
T - time needed to achieve outcome
Primary Care point of entry, gateway to health care services
Secondary Care acute - hospital
Tertiary Care complicated diagnostic services; hospital OR rehab
Palliative Care hospice services
health education groups, immunizations, physical/nutritional fitness, emotio
Primary Preventative Care
health, early detection and routine care
acute care, early diagnosis and prompt treatment, aims to prevent worsenin
Secondary Prevention
and/or complications, screenings for clients at risk
special care, restoration, rehab, permanent and irreversible, work to minimi
Tertiary Prevention
complication and further deterioration
Thermoregulation: Balance between heat produced and heat lost to maintain body temperatu
Expressed Consent Example: "Okay, we are taking your blood." PT gives arm
Implied Consent PT is not breathing, but no DNR
System within the hospital - login access only; permission required. (note th
Intranet
different than internet)
EHR Electronic Health Record
On call Dr. can skype or even treat. At times PT can call and speak to an RN
Telehealth
the phone
EMR Electronic Medical Record
Diagnosis Related Group: basis for establishing reimbursement for client ca
DRG (Medicare). Main problem with DRG's is when the PT care falls off the "expe
path of care"
, NUR 170 Final Exam Review
type of progress note
S - subjective
O - objective
SOAPIER A - assessment
P - plan
I - intervention
E - evaluation
R - revisions
type of progress note
PAO P - problem
A - action
O - outcome
type of progress note
PIE P - problem
I - intervention
E - evaluation
, NUR 170 Final Exam Review
type of progress note
DAR D - data
A - action
R - response
Focuses on documenting deviations from established norm or abnormal fin
(each facility has their own defined normal limits)
Charting by Exception (CBE)
Reduces documentation times and highlights trends and PT's condition
Can pose legal risks if RNs are not disciplined
OBRA Omnibus Budget Reconciliation Act of 1987
Terms NOT to use while documenting Passive words/phrases; example: appears, seems, apparently
BAD example: client seems anxious
GOOD example: client has increased pulse, increased RR, and increased
Examples of factual documentation
restlessness.
Client states "I feel anxious"
, NUR 170 Final Exam Review
P - patient population of interest
I - intervention of interest
PICOT C - comparison of interest
O - outcome
T - time needed to achieve outcome
Primary Care point of entry, gateway to health care services
Secondary Care acute - hospital
Tertiary Care complicated diagnostic services; hospital OR rehab
Palliative Care hospice services
health education groups, immunizations, physical/nutritional fitness, emotio
Primary Preventative Care
health, early detection and routine care
acute care, early diagnosis and prompt treatment, aims to prevent worsenin
Secondary Prevention
and/or complications, screenings for clients at risk
special care, restoration, rehab, permanent and irreversible, work to minimi
Tertiary Prevention
complication and further deterioration
Thermoregulation: Balance between heat produced and heat lost to maintain body temperatu
