Nursing 371 Exam 1.docx

Nursing 371 Exam 1
b b b




Study online at https://quizlet.com/_9yscap
b b b




1. Documentation Written or electronic legal record of all pertinent b b b b b b b b




interactions with the patient. b b b




-do this each time you assess, diagnose, plan, implement,
b b b b b b b b b




and evaluate (ADPIE).
b b




-______________=communication

2. Characteristics -consistent with professional and agency standards of b b b b b b b b




effective -complete documentation -accurate
b b b




-concise
-factual
-organized and timely b b




-legally prudent -confidential b b




it must be accessible, relevant, legible, facilitate care, and
b b b b b b b b b




used as a legal document b b b b




3. Data/ Documen- -facilitates quality, evidenced-based practice tation -
b b b b b b




financial and legal records
b b b




-clinical research b




-support decision analysis b b




4. Guidelines for -content documentation -timing
b b b b




-format
-confidentiality
-accountability

5. Confidentiality -all information about patients written on paper, spoken b b b b b b b b




aloud, saved on computer
b b b




-name, address, phone #, fax, social security b b b b b b




-reason the person is sick b b b b




-assessments and treatments patient receives -information b b b b b b




about past conditions b b




b b

, Nursing 371 Exam 1
b b b




Study online at https://quizlet.com/_9yscap
b b b




-personal information, diagnosis, tx, plan of care b b b b b b




6. What NOT to do
b b b -do not give information over the phone
b b b b b b




-do not give information without the patients permission
b b b b b b b




-do not give results to ANYTHING
b b b b b




7. True True or False b b




Anurse who fails to log off a computer after documenting b b b b b b b b b b




patient care has breached patient confidentiality. b b b b b




8. False- can't re- True or false vise
b b b b b




Apatient has the right to obtain, review, and revise the b b b b b b b b b b




patient information in his or her health record b b b b b b b




9. Patient rights -can see and copy their health record
b b b b b b b




-they can update their health record b b b b b




-they can get a list of disclosures b b b b b b




-they can request a restriction on certain uses or disclosures b b b b b b b b b b




in their information b b




-they can choose how to receive health information b b b b b b b




10. Patient Records b This includes the following: b b b




- Pt. Identification
b b




-Demographic data b




-Informed consent for tx and procedures b b b b b




-admission nursing hx b b




-nursing diagnosis and problems they are having b b b b b b




-nursing or multidisciplinary care plan b b b b




-Record of nursing care treatment and evaluation b b b b b b




-Medical history b




-Medical diagnosis b




-Therapy orders b




b b

, Nursing 371 Exam 1
b b b




Study online at https://quizlet.com/_9yscap
b b b




-Medical and health discipline's progress notes b b b b b




-Reports of physical examinations b b b




-Reports of diagnostic studies b b b




-Summary of operative procedures b b b




-Discharge plan and summary b b b




11.
Purpose of a pa- -Communication with other healthcare professionals tient
b b b b b b b b b b




record -Record of diagnostic and therapeutic orders b b b b b




-Care planning b




-Quality process and performance improvement b b b b




-Research
-Decision analysis b




-Education
-Credentialing, regulation, and legislation b b b




-Legal and historical documentation b b b




-Reimbursement
-Facilitate patient care b b




-Serve as a financial and legal record b b b b b b




-Help in clinical research b b b




-Support decision analysis b b




12. Guidelines for re- - Record the orders in patient's medical record ceiving
b b b b b b b b b b b b




verbal or- - Read back the order to verify accuracy ders in an emer- - Date and
b b b b b b b b b b b b b b b b b




note the time orders were issued in emergency
b b b b b b b




gency - Record VO, the name of the physician or nurse practi- b b b b b b b b b b




tioner followed by nurse's name and title b b b b b b




- The registered professional nurse must see that the orders b b b b b b b b b




are transcribed according to procedure b b b b




13. Medical termi- -used to facilitate communication nology
b b b b b




-broken down into the: b b b




-prefix b




-root b




b b

, Nursing 371 Exam 1 b b b




Study online at https://quizlet.com/_9yscap
b b b




b -suffix

14. black ink documentation should be done in
b b b b b




15. Legal document documentation is used as a __________ document.
b b b b b b b b b




•Contain facts and be accurate b b b b




•Legible b




•Brief/Concise
•Exact Time (may use military time) b b b b b




•Logical by time and content b b b b




•Errors/Omissions
•No blank spaces
b b




•Signature

16. Good documen- very descriptive and precise for the next person to undertation
b b b b b b b b b b b




stand. b




if you are a good assessor you will have...
b b b b b b b b




17. Charting Done during the following: b b b




•Admission
•Assuming care b




•Transferring a Patient b b




•Discharging a Patient b b




18. Type of charting - Newly admitted patient entries
b b b - Opening note for shift
b b b b b b b b




- Interval notes b




- Anything abnormal b




- Any change b




- Test, lab, doctor visit, dietitian-show orders carried out- b b b b b b b b




Transfer, discharge b





b b