NURS 326 Exam 5 Documentation and Informatics
Questions With Complete Solutions
Any ___ from the pathway is documented
Variance
How does a negative variance occur?
when the activities on the critical pathway are not completed as
predicted or the patient does not meet expected outcomes
IPOCs help administrators predict the
-length of stay
-monitor costs of care
-can assist with staffing
Flow sheets and graphic records are helpful in documenting
-Routine aspects of care (hygiene, turning, etc.)
-assessments organized by body systems
-response to care (wound care, pain, IV fluids)
-vital signs, daily weights
-intake and output
What are medication administration records (MAR)?
-comprehensive list of all prescribed medications
-provides information on medication allergies
-documents scheduled/routine, PRN, STAT, or omitted doses
How do you correct an error in handwritten documentation?
, -Keep the original document.
-Draw a single line through the entry and write "error" along
with your initials.
-Record the date and time of when the correction was entered.
-Do not obscure the original entry with anything such as white
out, black permanent marker, pen, pencil, etc.
-Document the correct information.
For electronic documentation, typically, within a ___-hour time-
frame, documentation can be edited by the writer provided the
patient has not been discharged
24-72
How do you correct an error for an electronic
documentation?
-Typically, within a 24 - 72-hour time-frame, documentation can
be edited by the writer provided the patient has not been
discharged.
-Where that timeframe has passed, documentation may have to
be corrected in the medical records department.
-Documentation will be marked as "erroneous" but remains
within the electronic record. It will not be apparent to casual
readers but will be discoverable to legal searches.
What are occurrence reports?
-Formal record of unusual occurrence or accident (medication
error, patient fall, etc.)
-not a part of client's health record
What are telephone orders/prescriptions?
Questions With Complete Solutions
Any ___ from the pathway is documented
Variance
How does a negative variance occur?
when the activities on the critical pathway are not completed as
predicted or the patient does not meet expected outcomes
IPOCs help administrators predict the
-length of stay
-monitor costs of care
-can assist with staffing
Flow sheets and graphic records are helpful in documenting
-Routine aspects of care (hygiene, turning, etc.)
-assessments organized by body systems
-response to care (wound care, pain, IV fluids)
-vital signs, daily weights
-intake and output
What are medication administration records (MAR)?
-comprehensive list of all prescribed medications
-provides information on medication allergies
-documents scheduled/routine, PRN, STAT, or omitted doses
How do you correct an error in handwritten documentation?
, -Keep the original document.
-Draw a single line through the entry and write "error" along
with your initials.
-Record the date and time of when the correction was entered.
-Do not obscure the original entry with anything such as white
out, black permanent marker, pen, pencil, etc.
-Document the correct information.
For electronic documentation, typically, within a ___-hour time-
frame, documentation can be edited by the writer provided the
patient has not been discharged
24-72
How do you correct an error for an electronic
documentation?
-Typically, within a 24 - 72-hour time-frame, documentation can
be edited by the writer provided the patient has not been
discharged.
-Where that timeframe has passed, documentation may have to
be corrected in the medical records department.
-Documentation will be marked as "erroneous" but remains
within the electronic record. It will not be apparent to casual
readers but will be discoverable to legal searches.
What are occurrence reports?
-Formal record of unusual occurrence or accident (medication
error, patient fall, etc.)
-not a part of client's health record
What are telephone orders/prescriptions?
